HomeMy WebLinkAbout15207 Springdale St - CofO (6)i
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SUPPLEMENTAL INFORMATION
1.
BUSINESS ADDRESS �'a0-� .SD2l�a�GL- OW
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2.
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Person to contact in case'' of emergency- �6
Telephone ; number:
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3.
Does the building in - question have :electricity?
Yes
it
❑ No
(a) If No, are you requesting that the electricity be
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turned on?
®" No
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4.
The building is sprinklered?
Yes
;
❑ No
5.
Operations will produce dust/wood shavings or similar
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material?
❑Yes
E
No
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6.
Operations will involve the ` repair or ;replacement of
❑ Yes
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automobile parts?
No
If Yes:
(a) Describe the components repaired or replaced.
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(b) Does the operation involve the use of an open flame?
❑Yes
10
No
7.
The business is 'drinking, dining or assembly use that will
result in an occupant load of more than '50 persons'.
❑ Yes
g No
8.
The following best describes my operation;
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Office Only
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Retail Sales
3,'Warehouse
/ Distribution (describe process and end prodt.Ict)
Ale fit'
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Restaurant / Take Out Food
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Medical / Dental
Other (describe)
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SUPPLEMENTAL INFORMATION V,
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SUPPLEMENTAL INFORMATION (Continued)
Does the operation involve any of the following materials? ❑ Yes
No.
If
.
Yes, indicate quantities;
Material Quantity
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1.
Flammable liquids
Class I -A
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Class I-B
Class I
2.
Combustible liquids
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Class II
Clasu 111-A
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3.
Combination flammable liquids
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4.
Flammable gases
5.
Liquefied flammable gases
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G.
Flammable fibers - Loose
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Flammable fibers -'baled
8.
Flammable solids
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Unstable materials
10.
Corrosive liquids
11.
Oxidizing material - gases
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Oxidizing material - liquids
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- oxidizing material - solids
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Organic peroxides
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15.
Nitromethane (unstable materials)
16_
Ammonium nitrate
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17.
Ammonium nitrate compound mixtures
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containing more than 60% nitrate
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by weight
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18.
Highly toxic material and
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poisonous gas
19.
Smokeless powder"
20.
Black sporting` powder
I hereby'; certify that the above information is true and correct to
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the best of n knowledge.
Signature Date
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