Laserfiche WebLink
- i • <br /> T'. 1 <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse "VED <br /> 222 East Weber Avenue <br /> Stockton, California 95202 JUN - 9 2003 <br /> Telephone (209)468-3962 <br /> Hazardous Materials Division (209)468-3969 iiY <br /> 0FEWG6WCV Sc+iVICk <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 Countyis required. <br /> Business Name: :, flp <br /> � IvlM�rk�1 r I�G �✓y r� / ^ f�j_ <br /> Business Owner(s) Name: <br /> /� Telephone: <br /> Business Address: fflqyv L 2 <br /> Mailing Address (if different from above)): <br /> Nature ouslness: /��/ m�u/ � Fire District: <br /> Q1. / OYgs eNo Does your business andle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on the back of this form. if your answer is <br /> NO.'go to Question 4. <br /> 02. j AY No Does material In a quantity equal to or greater than 55our business handle a hazardous tmixture <br /> gallons, 500 pounds,or 200cubic feet at <br /> any one time in the year? <br /> If'Yes,'how long have you handled these materials at your business? <br /> 1 <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 /> OB. This business is a health care facility(doctor, dentist,veterinary,eic.) and uses guly medical gases. <br /> OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYeslo Does your business handle an acutely hazardous material? See definition on reverse/���,,`!//''' side of this form. <br /> Q4. OYes A0 Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> I have read the inf/or`mation on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code. I understand that if 1 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 mel 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 of <br /> my knowledge. <br /> Owner or Authorized Agent: p- <br /> X Date: <br /> PL' <br /> X Title: /tcrsurer <br /> — <br /> Signature <br />