I, the undersigned, have read and answered the above questions truthfully and to the best of my ability. I understand that a site
inspection may be necessary at the business location due to the nature of my business and that the issuance of a business
license may be subject to the approval of other government agencies under contract with the City of San Dimas.
owner’s initial
Please answer yes or no to the following questions regarding your business activity:
Does your business use any type of chemical in your business activity? YES NO
If YES, type of Chemicals ___________________________________________________________________________
Does your business activity include food preparation? YES NO
If YES, list type: __________________________________________________________________________________
Will your operations include any processing, handling, storage or discharge of hazardous material, including chemicals and solvents? YES NO
If YES, list types: _________________________________________________________________________________
How disposed? ___________________________
______________________________________________________
Will your business generate any hazardous waste at this site? YES NO
If YES, list type: __________________________________________________________________________________
How disposed: ____
________________________________________________________________________________
Will you be discharging any waste other than domestic waste to the sewer system? YES NO
If YES, list type: __________________________________________________________________________________
Will your business operation include any welding or cutting? YES NO
Acetylene, Arc? ___________________________________________________________________________________
Will there be storage of any type of bottled gases, or more than 5 gallons of flammable liquid of any type? YES NO
If
YES, list types: _________________________________________________________________________________
Will your business operation include spray painting? YES NO
Will your operation be including sanding, cutting or shaping of wood products producing combustible dust or fibers? YES NO
Will there be storage of materials exceeding 12 feet in height or tire, plastic or flammable liquid storage over 6 feet in height? YES NO
Will there be repairs of vehicles beyond the simple exchange of parts? YES NO
Does your business currently have a Los Angeles County Industrial Waste Permit, and/or a State of California Storm Water Permit? YES NO
IF YES, to either, please enter permit numbers: Industrial Waste ______________ Storm Water ________________
Will your business activity include the sale of food or beverages for off-site consumption or the storage of food or beverages? YES NO
IF YES, submit copy of Los Angeles County Health Department permit.
Will your business serve alcoholic beverages? YES NO
IF YES, What type of ABC license? BEER WINE ALL ALCOHOL (Submit copy of License)
Will there be entertainment including, but not limited to, live performances (includes band, disc jockey) dancing, other? YES NO
If YES, list type: _________________________________________________________________________________
Live Entertainment requires an Entertainment Permit
Will there be arcade machines/amusements devices? IF YES, How many? _________ YES NO
Will there be any placement of new machinery, equipment or storage units outdoors or on the roof? YES NO
Will the business operation include any work, use or storage conducted outside of a wholly enclosed building? YES NO
Will you be doing any interior or exterior alterations or improvements to the building or grounds? YES NO
IF YES, please describe ____________________________________________________________________________
Is your business subject to any outside regulations and permits from any governmental agency? YES NO
IF YES, please describe____________________________________________________________________________
Does your business activity generate 4 or more cubic yards of waste per week? IF YES, Complete attached survey YES NO
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For Office Use Only
Planning Dept Approval ____________________
__________________ Public Works Dept Approval _______________________
Zoning ____________________________________________________ [ ] Need Clearance from LA County Industrial Waste
Bldg Dept. Approval _________________________________________ [ ] SIC________ NPDES Permit ______SW1 _____SW2
[ ] Need Permits for physical modifications to premises
[ ] Need clearance from LA County Fire Dept.
[ ] Special Conditions __________________________________________________________________________________
