San Bernardino County Fire Department Hazardous Materials Division

CUPA San Bernardino County Fire Department  Hazardous Materials Division 620 South ‘E’ Street, San Bernardino, CA 92415-0153  (909) 386-8401; FAX (909) 386-8460 www.sbcfire.org

PERMIT EXEMPTION REQUEST FORM

OWNER OWNERINFORMATION ID: (Office Use Only)

NAME: I ADDRESS:NAME: CITY:ADDRESS: STATE: ZIP CODE: PHONE:CITY: STATE: ALT PHONE: ZIP CODE: FAX: PHONE: ALT PHONE: FAX: REASON FOR EXEMPTION (see next page for further explanation): FACILITY INFORMATION FACILITY ID: (Office Use

have read and declare that this facility meets all of the requirements for exemption from the Business Emergency/Contingency Plan. I understand that if conditions change at my facility, I am required to contact the CUPA to file required paperwork and obtain permits.

Name (Print) Title

Signature Date

Office Use Only BUSINESS CODE: BUSINESS TYPE: SUPERVISORIAL DISTRICT: INSPECTION DISTRICT: BUSINESS DESCRIPTION: REVIEWED/APPROVED BY: DATE: PE: ENTERED BY: DATE: COMMENTS:

REQUIREMENTS FOR EXEMPTION

Note: Quantities are based on the maximum amount of hazardous materials and/or hazardous waste on site at any time. Materials in the course of transportation are exempt only when under active shipping papers.

1. Facility will not handle extremely hazardous substances exceeding threshold planning quantities or regulated substances exceeding threshold quantities. 2. Facility will not handle any quantity of:  Category I or II pesticides  DOT Class 1 explosives  Radioactive substances 3. Facility will generate no quantity of hazardous wastes. 4. Facility handles or will handle less than 55 gallons of a liquid, 500 pounds of a solid, or 200 cubic feet of any compressed gas

Additional exemptions may include: A. If the facility is a medical office only handling oxygen, nitrogen, or nitrous oxide in quantities no more than 1,000 cubic feet B. If the only hazardous material present at the facility is new lubricating oil and the total volume of each type of lubricating oil does not exceed 55 gallons and the total volume of all types of lubricating oil does not exceed 275 gallons at any one time. C. The only hazardous materials present at the facility is 300 gallons or less of propane used solely for heating employee work areas D. All hazardous materials exceeding these quantities are consumer products for direct distribution to, and use by the general public.