HomeMy WebLinkAbout15182 Triton Ln - CofO (13)tj
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SUPPLEMENTAL INFORMATION
1.
BUSINESS ADDRESS /�/ � 2 � lVl�✓ � Sc� /i�� /� %
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2.
Person to contact in case of emergency -
Telephone number: '7i�{ igf�7 �5 s
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3.
n electricity?
Does the building m question have e9ec y
�, Yes
,
❑ No
I
,
(a) If No, are you requesting that the electricity be
❑ Yes
'
turned -on?
❑ No
_
t
4.
The building is _sprinklered?
❑ Yes
WNo
5.
Operations will produce dust / wood shavings or similar
'
material?
Yes
'
6.
Operations will involve the repair or replacement of
❑ YLS
automobile parts?
'5 No
j
If Yes:
(a) Describe the components repaired or replaced.
„
s
❑ Yes
(b) Does the operation involve the use of an open flame?
PNo
'
7.
The business is drinking, dining or assembly use tnat will
ht
result in an occupant load of more than 50 persons.
El
a N
8.
The following best describes myoperation;
Office Only
Retail Sales
3
�
anufacturin istribution (describe process and end product]
a
Restaurant / Take Out Food
r
Medical / Dental
Other scribe)
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SUPPLEMENTAL INFORMATION
MANDX MY REPLY REQUIRED PRIOR TO ISSUANCE OF BUSINESS LICENSE
Complete and return this form to the Business Licensing D! -'sion
HUNTINGTON BEACH FIRE DEPARTMENT
HAZARDOUS MATERIALS DISCLOSURE
`INFORMATION SHEET
PLEASE PRINT
Business Address: ✓tZ/`roaf 44t, ' . —'Ek)/(�-/D/ Htg. Bch.
Number Street Unit 7- Zip Code
Business Name:_,,Pl;one: (ZI& �irodZ-61_1�
�'�- Q i
Own/r
er/Manager: Cy Asez, litle:
Description of business operation: (:-�As&
A Hazardous Materials Disclosure Forn must be completed and returned to the Fire
Department if any of the following are used, handled or stored in your business:
1. Any amount of chemical carcinogen.
2. Any amount of radioactive material.
3. Hazardous materials or haza-lous waste in amounts equal to or greater than 55
GALLONS (if liquid) or 500 POUNDS' (if solid) PER YEAR or 200 CUBIC FEET of
gas ON SITn 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.
- 4
Disclosure is not required for the following:
I. Hazardous substances contained in food, drug, cosmetic or tobacco products.
2. Upon approval of the Fire Chief, hazardous materials contained solely in
consumer products packaged for use by and distributed to the general public.'
However, pesticides, herbicides and ammonium nitrate fertilizers over the
required disclosure amounts are not exempt from disclosure. {
3. The transportation of hazardous materials accompanied by shipping papers
prepared in accordance with the provisions of 49 Code of Federal Regulations.
4. Infectious waste generated by health care facilities thet are regulated under Title,
22 of the California Administrates — Code.
CHECK ONE OF THE FOLLOWING:
No chemicals are used, handled or stored at this business.
Chemicals are used, handled or stored at this business, '-ut do not meet the
reauirements for disclosure.
_ Chemiclas are used, handled or stored at this business. (Disclosure required;
forms will be sent to you.)
Amounts will be verified during annual inspections. ` It is unlawful for any person to
knowingly violate ,any provision of this ordinance.
I certify, under the penalty of perjury, that the above information is true and correct to
the best of my knowledge.
Signature: 11�_ Home Phones {7i4 Date; 8 -/ i- �y
Questions regarding the Hazardous Materials Program, please call 714-536-5411.
0703F/13 (8/88)