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TOWNSHIP OF EWING Business Name:______________________________

DIVISION OF FIRE PREVENTION


Address:____________________________________
2007
Telephone #:____________BLK-______LOT______
OWNERSHIP INFORMATION
1. Name of Business Owner:______________________________________________________________

2. Address of Business Owner:____________________________________________________________

_____________________________________________________________

3. Phone # of Business Owner:____________________________________________________________

4. Name of Property Owner:______________________________________________________________

5. Address of Property Owner:____________________________________________________________

_____________________________________________________________

6. Phone # of Property Owner:____________________________________________________________

7. Officers of Business: (If Applicable)


NAME ADDRESS

BUSINESS INFORMATION
1. Type of Business:____________________________________________________________________
2. Fire Insurance Carrier:_______________________________________________________________

Policy Number:_________________________________Policy Amount:_______________________

3. Number of Employees: Full Time:__________________Part Time:___________________________

4. Floor Area of Business:_______________________________________________________________


EMERGENCY INFORMATION
This information will be kept on file with the Police Dispatcher and the Code Enforcement Office
in the event of a problem at your business after hours. Please list at least two names, preferably
those with keys and close enough to come out if needed by police or fire officials.

NAME___________________________________TELEPHONE #_______________________________

NAME___________________________________TELEPHONE #_______________________________

NAME___________________________________TELEPHONE #_______________________________
I hereby certify that the statements made by me on this application are true, complete and correct
to the best of my knowledge, and are made in good faith.

__________________________________ ______________________________ ___________________


NAME SIGNATURE DATE
TOWNSHIP OF EWING
DIVISION OF FIRE PREVENTION
EMERGENCY INFORMATION FORM

Name of Business:______________________________________________________________________

Address:______________________________________________________________________________

Telephone#____________________________________________________________________________

PART I: Hazardous Materials Inventory (if applicable)

Please list below any hazardous or toxic substances which are stored, manufactured, or
utilized by your business. If you need more space, or have a listing of your own, please submit along
with this form.

MATERIAL NAME QUANTITY WHERE STORED

1. ___________________________ __________________________ _________________________

2. ___________________________ __________________________ _________________________

3. ___________________________ __________________________ _________________________

4. ___________________________ __________________________ _________________________

5. ___________________________ __________________________ _________________________

6. ___________________________ __________________________ _________________________

7. ___________________________ __________________________ _________________________

8. ___________________________ __________________________ _________________________

9. ___________________________ __________________________ _________________________

10. ___________________________ __________________________ _________________________

11. ___________________________ __________________________ _________________________

12. ___________________________ __________________________ _________________________


PART II: Alarm Information
(Specify)
Is the property alarmed? Yes / No Type of alarm system: Burglar_____ Fire_____ Other________

Name & Address of alarm service company:________________________________________________

_________________________________________________

Alarm company telephone number:_______________________________________________________


EMERGENCY CONTACTS

Name__________________________________________________ Telephone______________________

Name__________________________________________________ Telephone _____________________


TOWNSHIP OF EWING BUSINESS NAME:
DIVISION OF FIRE PREVENTION ADDRESS:
PERMIT SURVEY TELEPHONE # :
TYPE I PERMITS TYPE IV PERMITS (CONT’D)
1. ______Bonfires
2. ______Torch to remove paint 3. ______Storage/handling of flammable
3. ______Tents exceeding 1200 sq. ft liquids in closed containers/tanks
4. ______Individual portable kiosks erected in a 4. ______Install/remove tank
covered mall for less than 90 days 5. ______Class I liquids in excess of 5 gal. in
5. ______Open flame in public assembly dwelling
6. ______Welding and cutting 6. ______Storage/use of Class II or III liquids,
7. ______Fireworks, explosives, blasting caps 25 gal. in building
8. ______Helistops 7. ______Storage of flammable/combustible
9. ______Occasional use for assembly liquids in tank
8. ______Manufacturing, processing or refining
TYPE II PERMITS 9. ______Storage or handing of the following:
1. ______Bowling Lane refinishing ______55 gal.of corrosives
2. ______Fumigation or fogging ______500 lb. oxidizers
3. ______Membrane covered, air supported ______10 lb. organic peroxides
structure ______500 lb. nitromethane
4. ______Carnivals, circus ______1,000 lb. ammonium nitrate
5. ______Use of covered mall for: ______1 millicurie of radium not sealed in
______Kiosks, display booth in more than source
25% of common area ______Dry amount of radioactive material
______Temporary place of assembly licensed by NRC
______Open flame ______10 lb. flammable solids
______Display of liquid/gas equipment
______LPG/LNE in 5lb. Containers- 10. ______Installation of LPG or LNG 2,000 gal.
(Storage outside of buildings of LP-gas cylinders when a individual or 4,000 gallons aggregate
part of a cylinder exchange program)
TYPE III PERMITS 11. ______Storage/use of 10 lb. of magnesium
1. _____Industrial furnaces gas/oil not 12. ______Heliports
exceeding 1400’
2. ______Wrecking yard or junk yard TYPE V PERMITS
3. ______Storage or discharge of fireworks
TYPE IV PERMITS 1. ______Airports
1. ______Storage / use of 2,000 cu. ft. of
flammable compressed gas
Owners/Occupant Certification:
2. ______Production or sale of Cryogenic liquids
I certify that the activities listed above are conducted
or storage or use of more than 10
at my premises:
gallons of LOX or flammable
______________________ ____________
Cryogenes
SIGNATURE DATE

Time/Date of Survey Name of Inspector Signature of Inspector

Inspection Number Staff Review Records


TOWNSHIP OF EWING BUSINESS NAME:
DIVISION OF FIRE PREVENTION ADDRESS:
TELEPHONE #:
LIFE HAZARD USE SURVEY
TYPE A LIFE HAZARDS TYPE B LIFE HAZARDS (CONT’D)

1. ______Service stations, repair, fueling 10.______Assemblies more than 100; museums,


2. ______Daycare center, day nurseries lecture halls, art galleries, recreation
3. ______Hotels, motels, 2 stories w. interior egress centers
4. ______Rooming, boarding homes, group homes, 11. ______Spraying with flammable, combustibles
residential nursing homes 12. ______Industrial processes:
5. ______Eating/drinking establishment (more than ______Explosive dusts
50) ______Crop ripening
6. ______Eating establishment more than 50, less ______Lumber yards w/more than 100,000ft
than 200 ______Tire recapping, rebuilding
7. ______Eating / drinking establishment ______Organic coating manufacturer/
(more than 50) producing 1 gal. or more per day
8. ______Above ground storage of flammable or ______Manufacturer of cellose nitrate
combustible (greater than 660, less than plastics
50,000) ______Handling of 100 cubic feet of loose
9. ______Dry cleaning with Non-flammable solvents combustible vegetable animal fibers
______Manufacturing of matches,
explosives
TYPE B LIFE HAZARDS ______Processing of flammable,
combustible liquids
1.______High Rise ______Welding/cutting, except Class I
2. ______Prisons, other restraint facilities permit
3. ______Institutions, including outpatient, dialysis, 13. ______Storage of the following:
alcohol treatment, abortion centers ______2500 cu.ft. packing cases, boxes
4. ______Movie theaters barrels
5. ______Eating/drinking, more than 50, less than 200 ______2500 cu.ft. tires, cotton, rubber,cork
6. ______Eating/drinking more than 200 ______25 lbs. cellulose nitrate plastic
7. ______Mercantile greater than 12,000 sq.ft. ______100 cu.ft combustible vegetable
8. ______Hotels, 4 stores or 100 rooms interior egress animal fibers
9. ______Windowless space, 50 or more, ______25 cases of matches
non-compliant ______Explosives, blasting agents
______50,000 gallons flammable/
I concur that these activities take place at my combustible liquids above ground
premises:
14. ______Dry cleaning with flammable solvents

15. ______Atriums 12,000 sq.ft., 3 stories


_________________________ ________________
OWNER/OCCPUPANT DATE
TYPE C LIFE HAZARDS
INSPECTOR’S SIGNATURE
1. ______Theatres with stage access, seating
2. ______Night clubs, 200 or more
3. ______Amusement (funhouses, haunted houses,
UCC USE GROUP RECORDS
etc.)
4. ______Institutional, hospital, nursing homes