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Au: 05 02 09: 42a San Joaquin DES 209-468-2600 P. 1 <br /> A0\ <br /> �� *1%0 Fi�CEIVED <br /> COUNTY OF SAN JOAQUIN <br /> AUG 2 6 2002 <br /> OFFICE OF EMERGENCY SERVICES RONALD <br /> RONALDI tpppUINGOS <br /> NEc <br /> ROOM 610,COURTHOUSE CODR�OFEMERENCYEO <br /> 222 EAST WEBER AVFNUL'- <br /> .p� STOCKTON,CALIFORNIA 95202 <br /> i.iN6'd~\ TFI.EPHONE(209)468 1962 <br /> HAZARDOUS MATERIALS DIVISION(209)468 1969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the infonnauun on the reverse side before completing chis survey form. A separate survey for each business name <br /> and/or address in San Joaquin County is required. <br /> Business Name: CLEMENTS RURAL FIRE L?ROTECTION <br /> Business Owners)Name: <br /> SAME AS ABOVE Tcicphonc,meq-759-1171 - <br /> - -- <br /> Business Address:_ 18901 E HWY 88, CLEMENTS, CA 99927 <br /> Mailing Address(if different from above): P n Rnx 593 G1 EMEUTS rA o S 227 <br /> Nature of Business: _ <br /> FIRE DISTRICT rife District: CLEMENTB <br /> - - — <br /> 01. (..7Ycs XINo Does your business handle a hazardous material in any quantity at any one time in the year? Seethe <br /> definition of hazardous material on the back of this form. It your answer is"No-,go w Question 4. <br /> Q7. I lYcs k INo Does your business hurdle 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 to the year! <br /> If"Yes".how long have you handled these materials at your business? <br /> If "Yea',check any of the following conditions that applies to your business? <br /> C: 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 /> i.7 B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses yTjjy medical gases. <br /> ;J C. This business operates a fano l'or purposes of cultivating the soil,raising.w harvestiflE an <br /> agricultural or horticultural commodity. <br /> Q3. iJYes IXNo Dors your business liandle an Acutely Hazardous ivlatcrial'! Sec definition on mvcrso side of this form. <br /> Q4. K'1Yes LJNo Is your business within I,OOo feu 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. 1 declare under the <br /> penalty of perjury that formation provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Own, tho ' ed Age : <br /> DAVE INGRUM Date <br /> X <br /> Print Name <br /> X Title <br /> Signature (Rei 10/96) <br />