HomeMy WebLinkAbout120 Pacific Coast Hwy - CofO (5)SUPPiLEI1MENTA"'� IT%FORMATION''
1.
BUSINESS ADDRESS
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2.
Person to contact in case of emergency- Htfd
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Telephone number:
3.
Does the building in questionhave electricity?
Yes
''
❑ No
(a) . If No, are you requesting that the electricity be
❑ Yes
it
turned on?
❑ No
4.
The building is sprinklered?
❑ Yes
5..
Operations will produce dust / wood ` shavings or similar
Material?:❑
Yes
No
6.
Operations ` will. 'involve the repair or replacement of
Yes—
automobile parts?
No
f
If Yes:
f
r
(a) Describe the coma, ,rents repaired or replaced:
❑ Yes
(b) Does the ,'::operation involve the use of - an open " flame? .
N'o
7.7
The business., is drinking, dining or assembly use that will.,
result"� in , an occupant load of more than 50' persons.
❑ Yes
5.
The following best describes rpy" operation,
,
fce O
R..ny
eales
1!Varehouse
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Manufacturing / Distribution '(describe process and end product)°".
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Restaurant / Take Out Food
Medical I Dental
Other (describe)
3
f;
�4�$�ypy A� 2 a
- A31aPPLEYl=wF94' dig 4�,FOL16Cti"if?ION
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SUPPLEMENTAL N ORMATION (Cor,,tinued)
Cues the Operationinvolve any of the foliawing rr�aterial ? ClYes
No
W, Yes, Andfcat6 quantifies
Material, Quantity`
1.
Flammable liquids
Glass i -A
Class I-P,
Class J l-C
r
2, "
Combustible !!quids
Claw d
Class f l; -A
- u
Comb►Gtion flammable l g iti;....
.:
r'feminable gases
5.
l~icui?#ied #iari�rnable' gases i
g.
u'Flarnmable #!hers - loose
7.
Flammable fibers baled
8:
l"larnmabie solids _-
9
iylnstable materials
10.
Corrosiye liquids
a
0 dizir g m4teria, `t. gases
�
CJxidizirtgrrraterlal - liquids
13r .
t)xidlzin ,.. Matnriai Of S.
14.
Organicperoxides
i
`
-Nitromethane - uristable` materials)
M
- Ammonium nitrate;
17.
;f A on om nitrate compound m;�ti�res
Gontaininr� mare, 'than 80% ;` nitrate
lay weight
18.,
Highly ;toxic material 'and
po�sonQus gas
19i
Smbkefess..pawd.er
2Q.
black spotting powder
g,
i., hereby certify. 'that the above information is, true snd .correct to
' the best of my knowla"dge.
-��— rate
Signature
`
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South Coast
AIR QUAL14T MANAGEMENT DISTRICT
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21865 E. Copley Drive, Diamond Bar, CA>91765-4182 (909) 396-2000
AI[t QUALITY PERAHr CHECKLIST
for nonresidential buildings only
Company Name ,. k�or. l� i c �.s ,•� z,4„ ,i,, l-.L
Location of Prop, rty l rt7 nil
City: Zip Code: JiQ q t
Contact Person:' _�r,,,. ��lr`,,� Title•`_ �a .�.
Telephone Number:, rt Fax Number: IM a6 W ,
Type of Industryt;, usiness:
I�
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To apply fora nonresidential building permit, you must comp • =e this clieckiist. h you have an Y "
questions about completing this checklist, please call (800) 388-2121 _
r
YES
NO
F
1.. Will the facility have a charbroiler? ]
;�
2. Will any ititetual combustion engine with greater than SO.horsepower
operate at the facility (excluding motor vehicles)?.(]
3. Will operations at the facility involve, mixing, blending, or processing%of
solvents, adhesives, paints or coatings? . ]
4. Will dust or smoke be generated at the facility?
5. Will refining of any Lgtuds or solids be done at the -,acility? ]
f
8. . Will any plating or coating of materials be done at the facility? [ ]
7: Will any combustion equipment rates, greater than 2,000,000.BTLT/hr be
operated at the facility? 1 ]
8' Will any acids, solvents, or motor fuel. be used or stored at the facility`? j ]
3. Will any organic liquids or gases be reacted or produced? ( ]
10 Will any ovens be used to dry or<cure products .at the facility?
1 l . Will any CI?C (Freon) recycling machines operate at the facili [ ]
(�
Applicant: Signature:
(Print name clearly)
If you have marked "NO'" inall the boxes, an air quality permit is t needed at this time,
and;this checklist is your writter► xelease.
If you marled "YES" in any of the boxes, you must contact the South Coast- Air Quality
41
Management District (AQI'vlD). f'Iease read the requirements (X_1the back of the checklist.
X
(Soo)-8$-2121
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Type of constructuon:
Stories & Height(f)
Sprinkling used?
❑Story Increase
i
❑Cdy Ordinance
❑Unlimited area
❑Ono hour construction'
❑Atria
E L/
❑Area Increase
❑cha ter9 6
i Area allowed:
i
Basic:
Yard:
Area separation;
Sprinkling;