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Dec 15 09 10: 37a Maria Montano 209-858-1663 p. 2 <br /> Dec 03 09 04:26p San .loaquin uo uta r- � <br /> COUNTY OF SAN JOAQUIN RECEIVED <br /> OFFICE OF EMERGENCY SERVICES DEC 14 2009 <br /> 4 2101 E.Earhart Avenue,Suite 300 <br /> STOCKTON,CA 95202 SAN JOAQUIN COU <br /> -�i TELEPHONE(209)933.6200 OFFICE OF EMERGENCYSERVICES <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business name andlor <br /> address in San Joaquin County is requi(r�ed. l <br /> BusinessName :�C�(:�ill(lb5 l� tfo 1'lt�Ajrr:ir Caw? I f KSM11�6Y1 Tole0MW d�'� .2.. —L�7�`I <br /> Business Site Address: �jc j3�; rto.'1 fy nt/a lAanfg co. Ch `I 5 3 :36 <br /> Mailing Address(if differwt from above): <br /> /� �1 <br /> Business Owners)Narne: 7`^t:�� 1 f L, l 1"t C. I-, +�-i Yl/�(�• Telephonekgj I H <br /> Business Owner Address: 15 ! I II hi.�cK—0—C, 1_. 4hY '1 Lh e5 3 0 <br /> Nature of Business: rl: h;' 1/ ___ Fire District LjCil,'AaCr-_ <br /> Ql. [B'6%; [2No Does your boniness handle a hazardous material in any quantity at any one time in the yea? See the r <br /> � <br /> // detinklon of hazardous material on the back of this form. If your answer is"No',go to Question 4, v jy G� 0 L <br /> QY <br /> Q2_ es �4o Does your business handle a hazardous material,or a mixture containing a hazardous material,in a <br /> quantityequal to or greaser than 55 gallons,500 pounds,or 200 cubic feet at any one time in the year? <br /> if-Yes",how tong have you handled these materials at your business? 6 <br /> If "Yes",check any of the following conditions that applies to your business? <br /> I� A. The hazardous materials handled by this business is contained solely in a consumer product packaged for <br /> direct distribution to,and use by,the general Public. <br /> ❑ B. This business operates a farm for purposes of cultivating the soi I,raising,or harvesting art <br /> agrimltural or horticultural commodity. <br /> Q3. []Yes 040, <br /> Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. [?res ONo Is your business within 1,000 feet orthe outer boundary of a school(grades K-12)? <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br /> Coda I understand that if 1 own a facility or property that is used by tenants,that it is my responsibility to notify the tenants of the <br /> requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> X M 01'1 Cly Date <br /> Print Na c <br /> X ?^ I Title I t/ <br /> Signature <br /> (Rev 8/08) <br />