Laserfiche WebLink
• � 'oPqu{N.• c <br /> e: <br /> I < <br /> 9�/FpRN RECEIVED. <br /> 7 COUNTY OF SAN JOAQUIN JAN 12 2009 <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse SAN JOAQUIN COUNTY <br /> 222 East Weber Avenue OFFICE OF EMERGENCY SERVICES <br /> Stockton, California 95202 <br /> Telephone (209)468-3962 <br /> Hazardous Materials Division (209)468-3969 <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 name <br /> and/or address in SanJoaquinCounty is required. <br /> Business Name: _ <br /> Business Owner(s)Name: /�iL1YQW..'.}--G r Telephone' <br /> Business Address: � g� r T11A1� r3 <br /> Mailing Address (if different from above): <br /> Nature of Business/: Fire District: <br /> Q1. OYes D 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. OYes t3 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 200c 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 apply to your business. <br /> OA. 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 /> OB. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. <br /> OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3. OYes QNNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> 04. OYes CKo 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: ��// 2_ Q' <br /> X Date: K4:0r" <br /> nt am ( __ <br /> X Title: GOI�T'ol[� <br /> gnature <br /> F'.SUIL NGWANWUM WIT AM-COMMERCIAL.0 FkN125(Rm.W 1436021 Page 4 of 5 <br />