TOWNSHIP OF FAIRFIELD

230 FAIRFIELD ROAD, FAIRFIELD, NJ 07004-2460

WILLIAM F. SMITH, FIRE MARSHAL

Bureau of Fire Prevention

Hazardous Chemical Control

(TEL) 973-882-2740

(FAX) 973-882-0365

e-mail: wsmith.fireprev@fairfieldtownhall.com

Permit Form

HAZARDOUS CHEMICAL CONTROL APPLICATION

PERMIT FORM

Permit#_______________________________ Date Filed:_____________________________________

Applicant:_____________________________ Address:_______________________________________ Tel:____________________ Block:__________ Lot:__________

Construction: ____________________________________________________________________________

Number Stories: ___________

Work Done: ______________________________________________________________________________

Date Issued: ______________________ Exp. Date:___________________________

The above named (Individual, Business) has made application to (Manufacture, Process, Handle, Use, Store) the following Hazardous Chemicals.

Hazardous CAS DOT Inventory Inventory

Material Number Number Max Amount Storage Location Fee Amt

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Addition Material (see attached): Annual Permit to Operate:

Total Hazardous Chemical Control fee:

In accordance with the provisions set forth in Local Ordinance #758 and other Federal, State and Local Regulations having Jurisdiction.

STATEMENT

I hereby acknowledge that I have read this application, that the information given is correct, and that I am owner, or duly authorized to act in the owner’s behalf and as such agree to comply with the applicable requirements of the Hazardous Chemical Control Ordinance.

Signed:____________________________________ Title:______________________________________________