HomeMy WebLinkAbout15171 Pipeline Ln - CofO (6)SUPPLEMENTAL INFORMATION
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1.
BUSINESS ADDRESS lei ¢d P,'�,ne ly1.
2.
Person to contact in case of emergency -
Telephone number:
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3.
Does the building in question have electricity?,
Yes
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❑ No
(a) If No, are you requesting that the electricity be
❑ Yes
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turned on?
❑ No
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4.
The building ,is spri,nklered?
❑ Yes
No
5.
Operations will - produce dust /wood shavings or similar
material?
❑ Yes
i„No
6.
Operations will involve the repair or replacement of
❑ Yes
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automobile; parts?
® No
If Yes:
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(a) Describe the components repaired or replaced.
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(b) Does the ` operation involve the use of an open flame?
❑ Yes
P' No
7.
The business is drinking, dining or ' assembly use that
will
result in an occupant load of more than 50 persons.
❑Yes
No
8.
The following best describes my operation;
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Office Only
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Retail Sales
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Man ufacturing / Distribution (describe process and end
product)
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Restaurant / Take Out Food
Medical / Dental
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Other (describe)
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SUPPLEMENTAL INFORMATION
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SUPPLEMENTAL INFORMATION (Continued)
Does the operation involve any of the following materials?
Yes
No
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If Yes, indicate quantities:
Material Quantity
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1. Flammable liquids
Class I -A
Class I-B
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i Class I-C-
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2. Combustible liquids
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- Class If
Class III -A
3. Combination flammable liquids
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4. Flammable gases
5. Liquefied flammable gases
6`. Flammable fibers - loose
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7. Flammable; fibers - bated
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B. Flammable solid
9. Unstable materials
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10, Corrosive ,liquids -
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11. Oxidizing material - gases
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12. Oxidizing ,material - liquids
13. Oxidizing :material - solids
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14� Organic peroxides
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15. Nitromethane (unstable materials)
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16. Ammonium nitrate
17. Ammonium nitrate compound mixtures
containing more than 60%' nit ate
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by weight
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1t3. Highly toxic material and
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poisonous ; gas
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19. Smokeless powder
20. Black sporting powder
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I here'ay certify that the above information is true and
correct, to
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the best of my knowledge.
ignature
Date
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South Cast
AIR QUALITY MANAGEMENT DISTRICT
21865 E. Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000
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AIR QUALITY PERMIT CfiECFa IST
for nonresidential buildings only
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Company Name:
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Location of Property:
City:{• a Zip Code:
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Contact Person: Titlers"`��.L'
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Telephone Number: �� /b r��3 Fax Number: 7f' Jam'
Type of Industry/Business: AGn s
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To apply for a nonresidential building permit, you must complete this checklist. ` If you have any,
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questions about completing this checklist lease call 800 388-2121.
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YES NO
1. Will the facility have a charbroHer?
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2. Will any internal combustion engine with greater than 50"horsepower
operate at the facility (excluding motor vehicles)?' (]
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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? (�
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�. Will refming of any liquids or solids be done at the facility? (]
6. Will any plating or coating of materials be done at the facility? (]
7. Will any combustion equipment rated greater than 2,000,000 BTU/hr be
operated at the facility?
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8. Will any acids, solvents, or motor fuel be used or stored at the facility?
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9. Will any organic liquids or Base; be reacted or produced? [
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10. Will any ovens be used to dry o* cure products at the facility? [
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11. Will any CSC (Freon) recycling machines operate at the faciH f9 [
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Applicant:Qnw signature: r
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(Print name clearly
If you have marked "NO" in all the boxes, an air quality permit is needed at this time,
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and this checklist is your written release.
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If you marked "YES" in any of the boxes, you must contact the South Coast Air Quality
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Management District (AQM- D). , Please read the requirements on the back of the checklist.
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(800) 388 2121
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SUPPLEMENTAL
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