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0 0 <br />COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE <br />STOCKTON, CALIFORNIA 95202 <br />TELEPHONE (209) 468-3962 <br />HAZARDOUS MATERIALS DIVISION (209) 468-3969 <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />RECEIVED <br />APR - 7 2006 <br />(m <br />�����JAN JUAUUIN GUUNTY <br />jt& i& DP% NGYSERVICES <br />DIRECTOR Of <br />EMERGENCY OPERATIONS <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: S PEE1lCy Telephone: nZ(ij -.G19- 7961 <br />Business Site Address: <br />Mailing Address (if different from above): <br />Business Owner(s) Name: Telephone: 765 Q JL _ <br />Business Owner Address: <br />Nature of Business: <br />Q 1. L[3'r 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 ❑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? 5fl&�9g <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 packaged for <br />direct distribution to, and use by, the general public. <br />❑ E. This busimtess operates a farm for purposes of cuidvating the soil, raising, or harvesting an <br />agricultural or horticultural commodity. <br />Q3. ❑Yes LSV O Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br />Q4. ❑Yes 040 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 />.,.6...,..., <br />d <br />9 <br />(Rev 3/05) <br />