HomeMy WebLinkAbout15131 Triton Ln - CofO (116)t
SUPPLEMENTAL INFORMATION
'BUSINESS 1,5131 D'
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1.
ADDRESS
2.
Person to contact in case of emergency -
Telephone number: 6 ' ZiZl�a3�
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3.
Does the building in question have electricity? �' Yes
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❑ No
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(a) If No, are you requesting that the electricity be Yes
turned on? ❑ No
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4.
The building is sprinklered? R-Yes
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R:-No
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5.
Operationswill produce dust / wood shavings or similar
material? ❑ Yes,k
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❑Yesrepair or replacement of6. Operations will involve the
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automobile parts?.fJo
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If Yes:
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(g) Describe the components repaired or replaced.
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(b) Does the operation involve the use of an open flame? ❑Yes
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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. ❑Yes
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8.
The following best describes my operation
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Office Only
Retail Sales
Wareho
nufact / Distrtbution (describe process and end product)
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Restaurant / Take Out Food
Medical / Dental
Other (describe) —
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SUPPLEMENTAL INFORMATION
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SUPPLEMENTAL INFORMATION, (Continued)
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Does the operation involve any of the following materials?
❑ No
If
Yes, ; indicate quantities:
Material Quantity
1.
Flammable liquids G"t
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Class I -A m +. a
Class I-B
Class i-C
2.
Combustible liquids
Class 11
Crass 111-A
3.
Combination flammable liquids
4.
Flammable gases
5.
Liquefied flammable _ gases,
6.
Flammable fibers -'loose`
7.
Flammable fibers - baled
4'
8.
Flammable solids
9.
Unstahle materials
10.
Corrosive liquids
11.
Oxidizing material - gases
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12.
Oxidizing material - liquids
13.
Oxidizing raterial - solids
14.
°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
by weight
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18.
Highly toxic material and
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a
poisonous gas
19.
Smokeless powder
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20,
Black sporting powder,
I hereby certify that the above information is true and correct to
the best o
my knowledge.
Signature Date
IF St �
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MANDATORY REPLY REQUIRED PRIOR TO ISSUANCE OF BUSINESS LICENSE
Complete and return this form to the Business Licensing Division
HUNTINGTON BEACH FIRE DEPARTMENT
HAZARDOUS MATERIALS DISCLOSURE
PLEASE PRINT INFORMATION SHEET
Business Address: Ls'i %Z Cj RRD
HtgBeh
Number Street Unit Zip Code
Business Name: , Phonq;,(%/ �,72%/
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Owner/Manager; ,J 1
k Title�
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Date of Occupation: If rental, number of units:
Description of business operation:�'�
A Hazardous Materials Disclosure Form must be completed and returned to the Fire
Department if any of the following are used, handled or stored in your business:
I. Any amount of chemical carcinogen.
2. Any amount of `radioactive material
3. Hazardous materials or hazardous waste in amounts equal to or greater than 55
GALLONS (if liquid) or 500 POUNDS (if solidi PER YEAR or 200 CUBIC FEET of �
gas ON SITE AT ANY ONE TIME. Hazardous materials are defined In Municipal
Code Chapter 17.58 and include materials for which the manufacturer or producer
Is required to prepare a Material Safety Data Sheet (MSDS). Hazardous waste Is
defined by Sections 25115 and 25117 of the. California Health and Safety Code.
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Disclosure is not required for the following:
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1. Hazarckwus substances contained in frx4 drug, cosmetic or tobacco products.
2. Upon approval of the Fire Chief, hazardous materials contained solely in
consuibez products packaged for use, by and distributed to the general publics '
However, pesticides, herbicides and ammonium nitrate fertilizers over the -
required disclosure amounts are not exempt from disclosure:
3. The tran3portation of haz—materialse accompanied by shipping papers
Prepared in accordance with the provisions of 49 Code of Federal Regulations.
4. Infectious waste generated by health care facilities that are regulated under Title
22 of the California Administrative Code.
CHECK ONE OF THE FOLLOWINGa
_ No chemicals are used, handled or stored at this business.
�Chemlcal; are used, handled or stored at this business, but do not meet the
requirements for disclosure.
Chemicals are used, handled or stored at this business. (Disclosure required;
forms will be, sent to youa
Amounts will be verified durina, annual Inspections. It is unlawful for any i)erson to
knowineiv vinin+^ ,,.,., _s —2S __ ..