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COUNTY OF SAN JOAQUIN <br /> �O. Q,CA <br /> OFFICE OF EMERGENCY SERVICES RONALD E.sALowtN <br /> m ROOM 610,COURTHOUSE coo ATOR <br /> 222 EAST WEBER AVENUE DECEIVED <br /> c�.. STOCKTON,CALIFORNIA 95202 <br /> ti c o R" TELEPHONE(209)468-3962 SCP — 9 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 3 2008 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEYONCE NJOAQUINCOUNIY <br /> MERGENCYSERWCES <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business name <br /> and/or address in San Joaquin County is required. <br /> Business Name: 1 `G�Otti N'Lo" —0�) k <br /> Business Owner(s)Name: Mt-u7^'A<A�S V 5A�L� qS� �� <br /> rv��..,.1�-� Telephone: <br /> �b l' Z <br /> � �* <br /> Business Address: l� I - CAy--Q- kIt�t"� 4S-T0Cv� 0(-J MMLA �n <br /> Mailing Address(if different from above): Wn» U� '�� �t��. 'l�lJ I A- fEe cGv <br /> CA <br /> Nature of Business: Fire District: <br /> Q 1. []Yes /*0 Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material on the back of this form. If your answer is`No",go to Question 4. <br /> Q2. GYes �No Does your business handle a hazardous material,or a mixture containing a hazardous material,in a <br /> quantity equal to or greater than 55 gallons.500 pounds,or 200 cubic feet at any one time in the year? <br /> If"Yes",how long have you handled these materials at your business? <br /> If "Yes",check any of the following conditions that applies to your business? <br /> IJ 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 is a health care facility (doctor,dentist,veterinary,etc.)and uses only medical gases. <br /> O C. This business operates a farm for purposes of cultivating the soil,raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. Dyes poNo Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. DYes 'ONo Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? <br /> I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br /> Code. I understand that if I own a facility or property that is used by tenants,that it is my responsibility to notify the tenants of <br /> the 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 <br /> Authorized Agent: <br /> g ` /�TPU— \1=FlF%{ Date <br /> 1, Print Name <br /> K M I i k Title mhS7rVQ1dN t-WJVX <br /> UuSignature 44> "�A�,r (Rev 10/96) <br />