City of San Diego FORM Development Services Child Care Center 1222 First Ave., MS-301 DS-527 San Diego, CA 92101 Hazardous Materials Substance (619) 446-5000 Approval Form JULY 2011
This completed form must be submitted to the County of San Diego Hazardous Materials Division (HMD), 5500 Overland Ave., Suite 110, San Diego, CA 92123, telephone (858) 505-6880, for their review before submitting to the Development Services Department. Their stamp is required on the bottom of the form. This form confirms that the Child Care Center complies with the Hazardous Materials buffer requirement contained in the City of San Diego Land Development Code, Section 141.0606. Project Address: Zip Code: Assessor Parcel Number(s): Project No. (For City Use Only)
Business Name: Contact Person: Telephone:
Mailing Address: City: State: Zip Code:
1. Describe the services and amenities to be provided, including any special care:
2. Number of Children: 3. Ages of Children: 4. Number of Employees: 5. Hours of Operation: 6. Expected dated of occupancy:
7. List all businesses within 1000 feet of the proposed Child Care Facility who have a potential to handle, store or generate regulated substanc es. If you need assistance on how to obtain this information, contact the County of San Diego Hazardous Materials Division at (858) 505-6880.
HMD I.D. No. ______Business Name:______
Business Address: ______
Type of Business: ______Distance from proposed Child Care Center:______
HMD I.D. No. ______Business Name:______
Business Address: ______
Type of Business: ______Distance from proposed Child Care Center:______
HMD I.D. No. ______Business Name:______
Business Address: ______
Type of Business: ______Distance from proposed Child Care Center:______
8. Applicant’s Certification - I hereby certify that, to the best of my knowledge, I have provided all of the information requested by the Hazardous Materials Division (HMD). I have made a thorough search of all HMD files, as noted, in order to complete this package. Under pen alty of perjury, I declare that to the best of my knowledge and belief the responses made herein are true and correct.
Name: Phone No.: Fax No.:
Address:
Applicant’s Signature: Date:
For County of San Diego Hazardous Materials Division use only
Regulated Substances Regulated Substances No Regulated Substances materials within 1000 feet of materials within 1000 feet of materials within 1000 feet of the site exceeding TQ’s. the site NOT exceeding TQ’s. the site.
Printed on recycled paper. Visit our web site at www.sandiego.gov/development-services. Upon request, this information is available in alternative formats for persons with disabilities. DS-527 (07-11) Page 2 of 4 City of San Diego • Development Services Department • Child Care Center Hazardous Materials Substance
List of businesses which require review by the County of San Diego Health Department, Hazardous Materials Division
The following list includes businesses which may use, store, handle or generate regulated substances work. Any business not on this list which handles regulated substances may still require HMD review.
AErOSPACE ELECTrONICS
Aerospace Industry Electronics Components Manufacturing Aircraft Manufacturing Electronics Assembly and Sub Assembly Aircraft Maintenance Printed Circuit Board Mfg.
AUTOMOTIvE METAL WOrkINg
Battery Manufacturing/recycling Anodizing Boat Yard Chemical Milling/Etching Car Wash Finish-Coating, Painting Dealership Maintenance and Paint Flame Spraying Machine Shop Foundry Painting Machine Shop-Drilling, Lathes, Mills radiator Shop Metal Plating rental Yard Equipment Metal Prepping/Chemical Coating repair, Preventive Maintenance Precious Metal recovery repair, Major Overhaul Sand Blasting, grinding Transportation Services Steel Fabricator Wrecking and recycling Wrought Iron Manufacturing
CHEMICAL HANDLINg
Agricultural Suppliers/Distributors OTHErS AND MISCELLANEOUS Chemical Suppliers/Distributors Chemical Manufacturer refrigeration Systems Coatings/Adhesives NOx Control systems Compressed gas Supplier/Distributor Asphalt Plant Dry Cleaning Chiropractic Offices Fiberglass/resin Applications Co-generation Plant gas Station Dental Clinic/Offices Industrial Laundry Dialysis Centers Laboratories Frozen Food Processing Facilities Laboratory Suppliers/Distributors government Agencies Oil and Fuel Bulk Supply Hazardous Waste Haulers Pesticide Operator/Distributor Hospitals/Convalescent Homes Photographic Processing Laboratories, Biological Laboratories Pool Supplies/Maintenance Medical Clinics/Offices Printing/Blue Printing Public Utilities road Coatings rock Quarry Swimming Pool (gas Chlorination Ship repair/Construction Systems Only) veterinary clinic/Hospitals Toxic gas Handler Wood/Furniture Manufacturer/refinishing Toxic gas Manufacturing City of San Diego • Development Services Department • Child Care Center Hazardous Materials Substance Page 3 of 4
Provide a vicinity map showing a one thousand foot (1000’) radius from the property line of your proposed Child Care Center indicating any businesses that handle regulated substances. See requirements in the City of San Diego Land Develpment Code, Section 141.0606(c). Page 4 of 4 City of San Diego • Development Services Department • Child Care Center Hazardous Materials Substance
SAMPLE VICINITY MAP
Block where hazardous materials are stored.
F Street
' 0 0 0 1
G Street
Park
Child Building Care ' 0 H Street 0 Center 6 Street
Parcel where nd nd 2 4th 4th Street 5th Street hazardous 3rdStreet materials are used.
I Street