Laserfiche WebLink
COUNTY OF SAN JOXQUIN <br /> I T cP <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse RECEIVED <br /> 222 East Weber Avenue <br /> ��p Stockton, California 95202 FEB 13 <br /> �f FOR Telephone (209)468-3962 <br /> Hazardous Materials Division (209) _468-39 SAN JOAQUIN COUNTY <br /> FICE OF EMERGENCY SERVICES <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 <br /> name and/or address in San Joaquin County is required. <br /> Business Name: --���✓(--�eS QA,t <br /> Ma✓r <br /> Business Owner(s) Name: R%.y v�._r-_ CIr _PCICAdGN- Telephone: FIl; — x-710 <br /> Business Address: l b(o&Z 9V UC.ke rst Y� CA- 7 <br /> Mailing Address(if different from above): <br /> Nature of Business: M,;z ZvI,&✓r C7h--1 Fire District: AA kll-� <br /> Q1. es ❑No 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. ❑Yes�Plo Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br /> \\�1 quantity 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, <br /> packaged 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 <br /> agricultural or horticultural commodity. <br /> Q3. ❑YesDoes your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yeskthe <br /> Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 have readformation on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code. I understand that if I own a facility or property that is used by tenants, that it is my responsibility to notify the <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I <br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best <br /> of my knowledge. <br /> Owner or Authorized�Aggent: <br /> XrA , �~ Date: LSI �,o10 <br /> Nam <br /> P 'nt (� <br /> X Title: ( r <br /> Signature <br /> F:\DevSvc\Planning Application Forms\Business License(Revised 10-20-05) Page 5 of 8 <br />