HomeMy WebLinkAbout15171 Pipeline Ln - CofO (5)SUPPLEMENTAL INFORMATION
BUSINESS ADDRESS /5 i/". uEt �vv 7 4
Person to contact in cases of emergency:� t2li.
Telephone n amber; (,0 9
3.
Does the building in question have electricity? ([Yes
s 13 No
a. If No, are you re qugsting that the electrici ry be QYes
turned on? ONO
�. A.
The building is sgr,i;akleredi OYes
19No
5.
Operations will produce dust/wood shavings or similar
material? 0Yes
ONO
6.
Operations will involve the repair or replacement of Des
automobile parts? �t�o
If yes
ia),_ Describe the components repaired or replaced.
i
(b) - Does the operation involve the use of an Open flame? OYes
,.
ONO
7.
The business is drinking, dining or assembly, usethatwill
result in an occupant lead of more than 50 persons. Mes
ONO
8.
The following best describes my operation;
Office Only
Retail sales
warehouse
Manufacturin /Distribsxt "on (describe garocess and nd ,
t i1 Q
.Pyre _
Restaurant `i`a `e Out Poo&
Medical/Dental,
Other (describe)
(0562D) (12/8/86)
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SU PLE.MENTAL INFORMATION (Continued)
Does
the operation involve any of the following
materials? Oyes
ONO
r
If Yes,
Quantity
_In lcate quant tl"
Material
1.
Flammable liquids
>
Class I -A
Class I-$
aisi
�y
Class I-C
2e
Combustible liquids
`
Class II
— --~--_ ---
w.
Class III -A
3.
Combination flammable liquids
E,
4,
Flammable, are
5
Liquefied flammable�asea �_��___
6.
Plarimable fibers loose
---------
7.
Flammable fibers - baledIJ
�� h
84
Flammable solids
-----
�
y',
unstable materials
`
10
Corrosive liqu.i.ds_
K 11
Oxidizing material - as'e, r
-------
12
Oxidizing materi al liqut_ds
—
13.
Oxidizing material solids
1•.,
Organic peroxides_
15.
Nitromethane (unstable materials)
16
Ammonium nitrate
17.
.Ammonium nitrate compound mixtures
containing more than 60% nitrat-
by weight
18.
Highly toxic material and
o;sonoua gas `
------
r,
19.
Smo'keless powder
20
Black s ortinc. powder
l
I hereby certify that the above information is
true and correct to the
best of my knowledge,
;
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Date
�
S gr atur
(0662D)
(12/8/86)
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