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s4V.!,N, <br /> SAN JOAQUIN COUNTY <br /> OFFICE OF EMERGENCY SERVICES j `J_ Lo GPI2 <br /> P 8 n DglBfdg kDeJr <br /> +r;;Foaa`� HAZARDOUS MATERIALS DISCLOSURE SURVEY PtZi n D�� '4t j`�il( � �{+ <br /> PLEASE PRINT OR TYPE <br /> Q1. Please provide a separate survey for each business name and/or address in San Joaquin County: <br /> a. Business Name: _ W0-4lylu', `` G.-)i,4- CLtAo enc Of' I oc4xP.�w��.11.rL� CtolrrCr�1J <br /> b. Business Owner(s) Name: U.k- kvLw G—s-+1 ( Gly J Phone: ZDc-L S5,i L2-1f- <br /> c. Facility Address: I(f%O IN, nW 56%1 <br /> W /n __C.� C 0 <br /> d. Mailing Address: Q V &)* ox <br /> 14 CU C.A- Gf Sy. l <br /> e. Nature of Business: �J�'J��G (r'lo\rc cUMP, Fire District: <br /> f. Business Lic. No: Expires (Mo/Yr) Standard Indstrl Code No: <br /> g. Proposed Project: <br /> h. If the business is not in operation, when is the approximate date of operation? <br /> 02. Does your business handle a hazardous material? 'Hazardous Material' means any material that, because of its <br /> quantity, concentration, or physical or chemical characteristics, poses a significant present or potential hazard to human health and <br /> safety or to the environment if released into the workplace or the environment. (Includes fuels, petroleum products, paints, <br /> Propane, oxygen, ammonia (AHM), chlorine (AHM), pesticides, fertilizers, and hazardous wastes...). <br /> Yes X No ❑ <br /> 03. If you answered 'YES' to Question 2 above: Do you handle a hazardous material or a mixture containing a hazardous <br /> material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time? <br /> Yes 11No 0 <br /> Q4. Will the owner, applicant, or future building occupant handle an Acutely Hazardous Material? (List of Acutely Hazardous <br /> Materials available at the Planning Department). <br /> Yes ❑ No 4Ol <br /> 05. Will proposed building or modified facility be within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> Yes ❑ No P <br /> I have read the Hazardous Materials Information Guide (on back page) and understand my requirements under Chapter 6.95 of the <br /> California Health and Safety Code Sections 25505, 25533, and 25534. 1 understand that If the building does not currently have a <br /> tenant, that It is my responsibility to noflfy the occupant of the requirements which must be met prior to issuance of a <br /> Certificate of Occupancy. I declare under the penalty of perjury that this disclosure survey is true and accurate to the best of <br /> my knowledge and is made in the City of California. <br /> Owner or/ 6 <br /> Authorized�df Agent: jj�� / L <br /> (Print) ✓O#A/ ,4-6 Title d1peQ�`---(�11 v- <br /> (Signature) <br /> Date <br /> 1. San Paquin Valley Unified Alt P ',({/p�iy1\–' - i0ffice o1 Emergency Services <br /> North Region Office I� J )tea lHazertlous Materials Division <br /> Mod Kiernan Ave.. Suite 730 1 I1222 E. Weber Ave., Courthouse-Room 610 <br /> Modesto, CA 95356 (209) 54 L$tockton, CA 95202 (209) 466-3969 <br /> 24-Hour Telephone: 1-600.287 APR 2 619 5 <br /> Fax: (209)-545-8652 -"UNTY DES INSP DATE /�V IFI/ <br /> y <br /> SER.. APPROVE REJECT-::I_ ED <br /> �OMMIJNI I f ULVLL� b� HMMP — RMPP — EXEMPT V.6.12/92 <br /> PLANNING f)IVINnn) <br />