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SUPPL EMENTAL INFORMATION'
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BUSINESS ADDRESS
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contact in `of emer enc.�G��
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Telephone number:
8.
Does the building in question have electricity?
d Yes
❑ No
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(a) If No, are you requesting that the electricity be
❑Yes
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turned on?
❑ No25
4.
The building is sprinklered?
Yes
❑ No
5.
Operations will produce dust/wood shavings or similar
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material?
Q No
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6.
Operations will involve the repair or replacement of
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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 flarne?
❑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 persons.
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No,
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`The following best describes my operation;
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office Only
Retail Sales
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ancturing / Distribution (describe process and end product)
Restaurant /Take Out Food
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Medical / Dental
Other (describe) ,
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SUPPLEMENTAL INFORMA110M
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SUPPLEfiRENTAL. CNFORNIATION (Continued)
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Does
the operation involve any of the following materials?
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If
Yes, indicate quantities:
Material Quantity
1.
Flammable liquids
Class I -A
Class I-8
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Class I-C
2.
Combustible liquids
Class II
Class III -A
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3.
Combination flammable liquids
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F
4.
Flammable gases
5.
Liquefied flammable gases
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6.
Flammable fibers - loose
7.
Flammable fibers - baled
6.
Flammable solids
9.
Unstable materials
10.
Corrosive" liquids
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11.
Oxidizing ' material - gases
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12.
Oxidizing material - liquids•
13..
Oxidizing material - solids
14.
Organic peroxides
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15.
Nitromethane (unstable materials)
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16.
Ammonium nitrate
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Ammonium nitrate compound mixtures
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containing more than 60% nitrate
by weight'
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18.
Highly toxic material and
poisonous - gas
19.
Smokeless powder
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20.
Buck sporting powder,
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I hereby certify, that the above information ' is true and correct
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the :best of m, knowledge;
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Signature Date
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South Coast
:. AIR QUALITY MANAGEMENT DISTRICT
21865 E. ':opley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000
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AM QUALITY PE_�iT CHECKLIST
for nonresidential buildings only
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Company Name: J
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Location of Property: 1 530
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City: l- U Zip Code: Zb
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Contact Person: 'V Title:
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Telephone Numb er:A 3 Fax
Number:
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Type of IndustryBwiness:
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, please call (800) 388-2121.
YES
L. Will the facility have a charbroiler? [ ]
NO
[
2. Will any internal combustion engine with greater than 50 horsepower
operate at the facility (excluding motor vehicles)?
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? ( ]
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? [ ]
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7. Will any combustion equipment rated greater than 2,000,000 BTU/hr be
operated at the facility? (]
8. Will any acids, solvents, or motor fuel be used or stored the facility?
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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?
11: Will any CFC (Freon) recycling machines operate at the facility?
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Applicant: J E �Lwt' " Signature: ✓�`
(Print name clearly)
If you have marked "NO" in all the boxes, an air quality permit is not 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
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Management District (AQMD). ;Please read the requirements on the back of the checklist.
(800) 388=2121
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r . ADDITIONAL SUPPLEMENTAL INFORMATION
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