Non-Residential Building Application Page 6
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8City of Auburn Hills
Hazardous Materials Disclosure and
Permit Application Form
This information is required by the City of Auburn Hills Hazardous Materials Disclosure Ordinance in
accordance with MIOSHA requirements, and may be used in the event of an emergency. Please be
as accurate as possible and type or legibly print all responses.
Business Name:
Nature of Business:
Business Address:
Phone:
Fax:
Property Owner:
24-Hour Phone:
Emergency Spill Contractor
Phone:
Primary Facility Contact:
Phone:
24-Hour Phone:
E-mail:
Alternate Facility Contact:
Business Phone:
24-Hour Phone:
E-mail:
I declare that the information on this form and the attached Chemical Survey
Form are true and accurate to the best of my knowledge.
Signature
Printed Name
Title
Date
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