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COUNTY OF SAN JOAQUIN <br /> ' OFFICE OF EMERGENCY SERVICES fiie <br /> f2101 E. EarhartAvenue, Suite 300 ��'��� <br /> Stockton, California 95206 <br /> I Telephone (209) 953-6200 JAN 21 2010 <br /> cgt'i F o p <br /> FAX (209) 953-6268 SAN JOAQUIN <br /> H RDOUS MATERIALS DISCLOSURE SURVEY <br /> OFFICE OF EM RGNCy S Ty <br /> R CR <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: C h�94� e2ll 4= t„ <br /> Business Owner(s) Name: r.L1 q 2 k�4 Telephone: <br /> Business Address: 1 S— w} 4.J 6 err �2 je;3M _�cz41 ✓L� <br /> Mailing Address (if different from above): `3 AC� Ct S �/?AC V jgl--V�p 7Z!�—c7z 4o--p 3cX17 <br /> Nature of B <br /> usi <br /> 'ness: � Fire District 10 l <br /> Q1. ❑Yes Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br /> of hazardous material on the back of this form. If your answer is No," go to Question 4. <br /> Q2. ❑Yes-I No Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br /> equal to or greater than 55 gallons, 500 pounds, or 200cubic 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 /> ❑A. The hazardous materials handled by this business is contained solely in a consumer product, packaged <br /> for 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 /> ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3. ❑Yes [�No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes Colo 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 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 C "4kt-A J Date: <br /> �j Print Name �* <br /> X b � �� Title: <br /> Si nature <br /> F:\DevSvc\Planning Application Forms\Business License(Revised 11-16-09) Page 4 of 7 <br />