HomeMy WebLinkAboutX2011-1483 - Misc4f IIUle U "ft 4045
CITY OF NEWPORT BEACH
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
3300 Newport Boulevard I P.O. Box 1768 I Newport Beach, CA 92658
www.newportbeachca.gov I (949) 644-3275
HAZARDOUS MATERIALS QUESTIONNAIRE
If the answer to any of the questions below is yes, applicant must contact the Fire Prevention Office, 3300
Newport Boulevard, P.O. Box 1768, Newport Beach, CA 92658-8915. Telephone: (949) 644-3106.
Business Name
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Mailing Addfess
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Site Address
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YES NO
❑ n Will your business activity generate Hazardous Waste in any quantity, in any physical
form (solid, liquid, gas)?
State
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Zip
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Contact Person
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City
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Will your business at any one time store, use or handle Hazardous Substances in
quantities
equal to or greater than 55 gallons, 500 pounds or 200 cubic feet of compressed gas?
3. Will your business store, use or handle Carcinogens or Human Reproductive Toxins in
any amount?
4. ❑ Q/ Will your business use an existing or install an Underground Storage Tank for
Hazardous Substances or Hazardous Wastes?
5. Will your business store, use or handle Acutely Hazardous Materials?
6. ❑ �� If your business will be handling Acutely Hazardous Materials, will your business be
located within 1,000 feet from the outer boundary of a school?
❑ ILK'
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Briefly describe the nature of the business activity: .
Printed Name of Respondent:
Circle one: owner lessee geri
tenant architect engineer
I declare under penalty of perjury that to the best of my knowledge and belief the responses made herein are true
and correct. 4
Sign2ftur
of Responde
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Date
For NBFD-Fire Prevention Use Only
Business Plan Required
YES NO Reviewed By.
❑ ❑
Date:
Plan Check No:
05/12/11 - - -
Forms\Hazquest
South Coast
Air Quality Management District
21865 Copley Drive, Diamond Bar, CA 91765-4182
(909) 396-3529 • http:// www.aqmd.gov
Air Quality Permit Checklist
California Government Code Section 65850.2 prohibits cities from issuing an occupancy permit
to a business without clearance from the local air quality agency. This Checklist will determine
if you need to obtain clearance from the South Coast Air Quality Management District (AQMD).
Company Name: CTa e �i /fa ce
Property Address: 014-t� ✓44-,gets be,v c_
City: tt` e.A/ Qe. e.:i... Zip Code: C 11 q
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Contact Person: �J4�e
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Type of Business: YSe Telephone: g lI 1 76 E(- t i t t (O t{
Fax Number: y/// 7 Co (-(-63 3 e-mail address: 6, ►1 es l v ...,, 7 (4r a5 was? , O J
Applicant (print name): t 4w. Loj9 2- Signature: cl
Date: %— fly—. Zu ((
• Will the facility have any of the following equipment? Yes ❑ No L�
Charbroiler
Dry cleaning machine
Spray booth
Printing press (screen/lithographic/flexographic)
Internal combustion engine greater than 50 HP (excluding motor vehicles)
Boiler/combustion equipment (greater than 1 million BTU/hr. maximum input)
Abrasive blasting cabinet/room
Baghouse/cartridge-type dust filter/scrubber
Motor fuel storage and dispensing equipment
• Will any of the following operations be performed? Yes n No
Application of paints or adhesives
Etching, plating, casting, or melting of metals
Molding, extruding, or curing of plastics
Mixing and blending of liquids and/or powders
Storage of acids, solvents, organic liquids, or fuels
Production of fumes, dust, smoke, or strong odors
If you answered "No" to both questions, this checklist is your clearance from AQMD. If
you answered "Yes" to either question, you must contact AQMD to determine if air quality
permits are required. If permits are needed, AQMD will assist you in submitting permit
application(s) and then provide you with a clearance letter. You can call AQMD at their Small
Business Assistance Office at 1-800-CUT-SMOG (1-800-288-7664).
Revised November 2006