HomeMy WebLinkAbout15209 Springdale St - CofO (4)'I
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SUPPLEMENTAL IF FORMATION
1.
BUSINESS ADDRESS Sipo'/xacw �}. � _ 926 Y<9
2.
Person to contact in case of emergency,
Telephone number: `7/�/ 9.3Y=9663
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3.
Does the building in question have electricity?
Yes
❑ No
(a) If No, are you requesting that the electricity be '
❑ Yes
,
turned on?
❑ No
4.
The building is sprinklered?
Yes
t
❑ No
5.
Operations will `produce dust /wood shavings or similar
material?
❑Yes
ONO
6.
Operations will involve the repair or replacement of
Yes
automobile parts?
X.No
If Yes:
-(a) Describe the components repaired or -replaced.
(b) Does the operation involve the use of an open flamA?
❑Yes
�No
7.
-The business is drinking, dining or assembly use that will
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result in an, occupant load of more than .50 persono.
❑ Yes
g No
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8.
The following best describes my operation;;
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Office Only
.:
Retail Sales
Warehouse
Manufacturin = istributio (describe process and end product).
rch�s� Gt,-ie� C� �s-t-rt��-l-e� �% a» tr_..s � -•
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Restaurant / Take Out Food
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Medical /Dental
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Oth•, describe
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SUPPLEMENTAL WORMATION _
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SUPPLEMENTAL
INFORMATION (Continued)
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Does the, operation involve any of the
following materials? ' 0 Yes,
WNo
If
Yes, indicate quantities::
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Material
Quantity
1.
Flammable liquids
Class I -A
Class 1-B
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Class I-C
2.
Combustible liquids
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Class I i
Class III -A
3.
Combination , flammable :liquids
4. -
Flammable gases
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5
Liquefied flammable gases
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Flammable fibers - loose
?'.
Flammable fibers - baled
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8
Flammable solids
M
9.
Unstable materials
10.
Corrosive liquids
4
;.
1T.
Oxidizing material - gases
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12.
_Oxidizing -material - liquids
13.
Oxidizing material - solids
14.
Organic peroxides
15.
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Nitromethane (un table 'ma#erals)
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16,
:Ammonium nitrate
17.
Ammonium nitrate compound:'- mixtures
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containing more than 60% nitrate
by weight
18.
Highly toxic material and
poisonous gas.
t 19.
Smokeless: powder
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20.
B*K sporting powder
1, ,hereby certify that the above information _is. true.` acid - correct to
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the best of my knowledge.
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Signature
Date
`i""y
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South Gast
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Alfa QUALITY MANAGEMENT DISTRICT
,
21865 E. Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000
AIER QUAiLTT3�' PERMIT CHECKLIST
for nonresidential buildings only
��5/C �'GGCGtG.st� �aPPL�(Nc�
Company Name: �
s
Location of Property:l' Z n K le
City: Zip Code:269
,
4A�o ay L�i33 Title:i"�s t c�ea t
Contact Person:
Telephone Number: 7 Al 93 q Fax Number: 7/ y F3'��8 S3
Type, of Industry/Busir.ess:
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To apply for a nonresidential building permit, you must complete this checklist. If you have any
questions about completing this checklist, please call (800) 388-2121.
YES
[ ]
NO
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1'. Will the facility have a charbroiler?
4 2. Will any internal combustion engine with greater than 50 horsepower
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operate at the facility (excluding motor vehicles)?
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3. Will operations at the facility involve mixing, blending, or processing of
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solvents, adhesives, paints or coatings?
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4. Will dust or smoke be generated at the facility?
[ ]
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5. Will refining of any liquids or solids be done at the facility?
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6. Will any plating or coating of materials be done at the facility?
7. Will any combustion'equipment rated greaterthan 2000,000 BTLT/hr be
is
i, operated at the facility? [` J
8. Will any acids, solvents, or motor fuel be used or stored at the facility? [ J
9. Will any organic liquids or gases be reacted or produced? [ ]
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10. Will any ovens be used to dry or cure products at the facility?
the faci ' ? J
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11. Will any CFC (Freon) recycling machines operate at
Applicant: Sz7N . T`p'3-B Signature:
(Print name clearly)
F Ifyou have marked "NO" in all the boxes, an air quality permit is needed at this time,
and this checklist is your written release.
If you marked "YES" in any of the boxes, you must contact the South Coast Air Quality
Management Dists et (AQM D). Please read the requirements on the bank of the checklist.
(800) 388-2121NFO
7.
ADDITIONAL SUPPLEMENTAL INFORMATION
77
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