HomeMy WebLinkAbout042-090-088 CF ArchiveBUTTE COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
HAZARDOUS MATERIALS AND EMMISSIONS QUESTIONNAIRE
(A Building Permit cannot be approved without this completed form.)
BUILDING PERMIT NUMBER
Firm Name
Address
Nature of Business
Contact Person _
APN
Phone #
1. Does your business or that of your tennants handle, store, or transport hazardous materials?
❑ NO ❑ YES
NOTE: Hazardous materials are defined as any material that, because of its quantity, concentration, or
physical or chemical characteristics, poses a significant present or potential hazard to human
health and safety or to the evironment if released into the the workplace or the environment.
"Hazardous Materials" include, but are not limited to, hazardous chemicals, hazardous waste,
paints, oils, lubricants, fuels, flammables, combustibles, corrosives, gases, and any material which
a handler or the administering agency has a reasonable basis for believing to be injurious to the
health and safety of persons or harmful to the environment if released.
2. Do you or will your future tenants handle store, or transport 55 gallons, 500 pounds, or 200 cubic feet (at
standard temperature 4 pressure), or formulation containing hazardous material?
❑ NO ❑ YES
If you answered YES to 1 or 2, contact the Butte County Environmemtal Health Department (916-538-7281) for
a review of the project.
3. Is the business/facility/operation to be located within 1000 feet or the outer boundry of a school or
school site?
❑ NO ❑ YES
IF YES, name of school.
4. Does the business/facility/operation have the potential to emit any air pollutants; e.g., dust, soot, odors,
fumes, vapors, or other volatile compounds?
❑ NO ❑ YES
IF YES, contact the Butte County Air Pollution Control District (916-891-2882) for permit requirements.
Owner or Authorized Company Representative
(Signature)
BCEHD BCAPCD
E] M
El
BCEHD Signature
BCAPCD Signature
(Date)
The applicant has met or is meeting the applicable requirements of Section 25505,
25533, and 25534 of the Health and Safety Code and the requirements for a permit
from the Butte County Air Pollution Control District.
The Above Regulations Do Not Apply To This Facility.
Date
Date
WHITE- Building Dept ❑ YELLOW- Env. Health 0 PINK - APCD 0 GOLDENROD- Fire Dept.