HomeMy WebLinkAbout15171 Pipeline Ln - CofO (3)i
SUPPLEMENTAL INFORMATION
1.
BUSINESS ADDRESS �S12 � Pl �� Lj nf� LA_nJff
2.
Parsonto contact in „case of emergency
, ,
Telephone number: F 71q - 261 = �-'3 S
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3.
Does the building in question have electricity? 6-yes,
❑ No
(a) If No; are you requesting that the electricity be ❑Yes
turned on? _ ❑ No
x
4.
The building is-sprinklered? Yes
❑ No
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5.
Operations will produce dust/wood shavings or similar
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rh6terial? ❑ Yes
'No
6
' ' Operations will involve the repair or. replacement-, of ❑' Yes-`
automobile parts?.No
If Yes:
G. . ' ;
(a) Deucribe the components repaired or replaced)
(b) Does the operation involve the use of :an open flame?,,, `.0 Yes
No
7.
The business is - drinking,- dining or assembly ' use that will
result in an, occupant load ;of more than:.' 50.. Isersons.. ._❑ Yes:`
�-
8.
The following best describes my' operation;, ,
Office Only
�-`
Retail Sales
Warehouse
ManufacturinaJ Distribution (describe ,process and.end product)
Restaurant / Take Out Food
Medical/ Dental
)
Other (describe),
SUPPLEMENTAL INFOh,MATION
{
5tPPLNRBiAL INFORMATION- Continued
Does the operation `;Involve ...any of the followging niaYerial 7 µEl "
Yes
No
if fes, indicate quantities: --
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Material Quantity
1. Flammable liquids
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:Class 1-A
Class I-B —
_
Class I-C ?,
2. Combustible liquids
i
Class i I
Class 11I-A
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3. Combinationflammable ,.liquids
4. , °Flammable gases -
5. Liquefled flammable gases
6• Flammable fibers - loose
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7• Flammable fibers - baled
8• Flammable solids
9• Unstable materials
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10. Corrosive liquids
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11 Oxidizing rtmater alY-'gases -
12: , _ .Oxldi,4ing material-Fllqulds
13 Oxidizing, material -solids.. „_..,
14. �Or anic peroxides
15 .Nitr'ametliane' unstable -
,materials). ,
ice+(,.
.. . ,
Ammonlum nitrate
'f
17. µ Ammonium nitrate compound
containing more than 60%u nitrate
} by weight
f
18. Highly toxic material and
r`.
Poisanaus gas
-Smokeless. powder,
20. Black sporting, powder
_. .
,
I .hereby_...cer.tify, that, -the.,.. ,above -information. is .true. and- .corrects tok
>, the best
�� my kno/wledge.
Signature Date
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4S
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