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CITY OF NEWPORT BEACH
112-.S Al ew ("It T
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OR
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
www.newportbeachca.gov 1 (949) 644-3200
HAZARDOUS MATERIALS QUESTIONNAIRE
If the answer to any of the questions below is yes, applicant must contact the Fire Prevention Office, 100 Civic
Center Drive, P.O. Box 1768, Newport Beach, CA 92658-8915. Telephone: (949) 644-3106.
Business Name
Contact Person
Telephone
Allbirds, Inc
Elias Abu Shanab
510-501-0227
Mailing Address
City State
zip
730 Montgomerry Street San Francisco CA
94111
Site Address
City
zip
1125 Newport Center
Drive Newport Beach
92660
YES NO
1. ❑
Will your business activity generate Hazardous
Waste in any quantity, in any physical
form (solid, liquid, gas)?
2. ❑ X
Will your business at any one time store, use or handle Hazardous Substances in
quantities
equal to or greater than 55 gallons, 500 pounds or 200 cubic feet of compressed gas?
3. ❑
Will your business store, use or handle Carcinogens or Human Reproductive Toxins in
any amount?
4. ❑ X
Will your business use an existing or install an Underground Storage Tank for
Hazardous Substances or Hazardous Wastes?
5. ❑ Will your business store, use or handle Acutely Hazardous Materials?
6. ❑ ❑ If your business will be handling Acutely Hazardous Materials, will your business be
located within 1,000 feet from the outer boundary of a school?
Briefly describe the nature of the business activity:
Shoes & apparels retail store in Fashion Island Shopping Center
Printed Name of Respondent: Circle one: owner lessee agent
Theresia Kurnadi(Goring & Straja Architects) tenant architect engineer
I declare under penalty of perjury that to the best of my knowledge and belief the responses made herein are true
and correct. A;�� 11/01/2021
Signature of
Date
For NBFD-Fire Prevention Use Only YES ` NO - Reviewed By: Date:
Business Plan Required ❑ ❑ -
Plan Check No.
Forms0azquest 3111/09'.