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Home My WebLink AboutB2004-0130 - MiscQDy'/— .27DQ L' CITY OF NEWPORT BEACH FIRE DEPARTMENT 3300 Newport Boulevard, P.O. Box 1768, Newport Beach, CA 92658-8915 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: (714) 644-3106. Business Name Contact Person HOAG t1PhoRl #l- HOSPITAL GKE G Mailing Address ONE t94,46 DR Telephone ii c, C L UR E (94 9) Sly - 'r 4 i 7 City State Zip AIEUiPORT tE#cW CA- 926Sg ' Site Address Otis hWOA6 A. City ova wporr /S r-A- c /4- Zip 3 2 658 YES NO 1. 2. ❑ VI 3. Will your business activity generate Hazardous Waste in any quantity, in any physical form (solid, liquid, gas)? 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? Will your business store, use or handle Carcinogens or Human Reproductive Toxins in any amount? 4. ❑ ® 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. ❑ El 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? 7. ❑ ® Is your business identified under Item VIII of the Disclosure Requirements for Hazardous Materials? Briefly describe nature of the business activity. CRISTiNA PE12Ry Printed Name of Respondent: Circle one: owner tenant agent lessee rc ect engineer I declare under penalty of perjury that to the best of my knowledge and belief the responses made herein are true and correct. Signature ofResfondent Date For NBFD-HMMS Use Only; Business Plan Re4dired <. Risk Management & Preven Fonnsltiazquest39$doP,. PlanlCheck l�to' f South Coast AIR QUALITY MANAGEMENT DISTRICT 21865 E. Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000 AIR QUALITY PERMIT CHECKLIST for non-residential buildings only Location of Property: OM E 1+0,46 D .—AJE t) PORT &EMCfl Zip Code 92658 Company Name: f i-M-G 1--OSPI TA L ?RES By r&ael.4y.i Contact Person: GREG HCCLU RE Title: ?ROJ ecr g1ANA-GE,e Telephone Number: `t rq — 5 7 4 — 44 77 Fax Number: Type of Industry/Business: PIENIOKO FF(C-6 Any person applying for a non-residential building permit must complete this checklist. If you have any questions about completing this checklist, please call 1 800 388-2121 for assistance. 1. Will the building house a restaurant (with a charbroiler)? 2. Will any internal combustion engines with greater than 50 Horse Power operate at the facility? (excludes motor vehicles) 3. Will operations at the facility involve the mixing, blending, or processing of solvents, adhesives, paints or coatings? 4. Will any dust or smoke be generated at the facility? 5. Will refining of any liquids or solids be done at the facility? 6. Will any plating or coating of materials be done at the facility? 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 handled or stored at the facility? 9. Will any organic liquids or gases be reacted or produced? 10. Will any ovens be used to dry or cure products at the facility? 11. Will any CFC recycling machines operate at the facility? Person Preparing this Form : Name: CR ISTlNA it RR)/ Signature: yr�C (Print Clearly) If you have marked "No" in all the boxes, an air quality permit is not needed at this time. This checklist is your written release. If you marked "Yes" in any of the boxes, you must contact the South Coast Air Quality Management District (AQMD). Please read the requirements on the back of the checklist. 1 800 388-2121 (FAX 1909 396-3335) revised 8/26/94 NOTICE OF GOVERNMENT CODE SECTION 65850.2 (AB 3205) REQUIREMENTS California State Law (Govt. Code 65850.2) prohibits the Building Departments from issuing a final certificate of occupancy unless all requirements of the local air quality agency are met. All applicants are required to complete the air quality permit checklist. The checklist is designed to aid the applicant for non-residential buildings only and excludes motor vehicles. If the answer to any of the questions is "YES", the Building Department must obtain a written release from the local air quality agency verifying that the applicant is in compliance. 1. All non-residential building permit applicants must complete this checklist. 2. If the answers to all questions are "NO", the Building Department can accept the checklist as the written release. 3. If any questions are answered "YES", the applicant must contact the District by calling 1 (800) 388-2121 to determine whether air quality permits are required for any equipment which may be operated at the site. If the District determines that air quality permits are not required or that all requirements have been met, a written release will be issued. 4. If air quality permits are required and applications have not been submitted, the applicant must submit the necessary permit application(s) and appropriate fees before a written release will be issued. AQMD is committed to expediting all clearance letter requests. However, it may take several weeks to verify compliance with all requirements. Therefore, you are advised to contact AQMD immediately after applying for building permits. 1 800 388-2121 • • •• 0 ..—... . a • • OM CS 0111 .rt. Y • w. Q 1 ,T�"LStr r i r, y1 w • Ai Dix c I • PpepUVP`` 01‘ M