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53 <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> ROOM <br /> 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> TqD <br /> STOCKTON,CALIFORNIA 95202 <br /> TELEPHONE(209)468-3962 rr'�, OEC 2 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 p <br /> 1997 <br /> HAZARDOUS MATERIALS SURVEY FORMA—![! ' INM' <br /> t"' <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 San Joaquin County is required. / <br /> Business Name: 02eN..r�n �Jc �(7 t-'.( tiaLoo✓M'/L� <br /> Business Owner(s)Name: ie'i�P� 1 � '� Telephone: 7-001 "957 ' 2�2 0 <br /> Business Address: /0l5 NA�40*L /-A-u6 <br /> Mailing Address(if different from above): <br /> Nature of Business: /iDur 6 /9.t02C42 VAA411 jT 44A1Ja/ �1A1U/L56� Fire District: <br /> Q 1. EXes ONO 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. Wes ❑No Does your business handle 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 in the year? <br /> If"Yes",how long have you handled these materials at your business? /5 <br /> If "Yes",check any of the following conditions that applies to your business? <br /> IXA. 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 /> ❑ 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. ❑Yes MNo Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. []Yes ONO 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 <br /> the 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: <br /> X --64rJ k�7--r!r Date 11-ZI- R7' <br /> —I! <br /> X Print Name <br /> C Title fin,.vr <br /> Signature (Rev 10/96) <br />