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COUNTY OF SAN JOAQUIN <br /> r. <br /> ?4 � OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> ? ROOM 610,COURTHOUSE COORDINATOR <br /> b: <br /> 222 EAST WEBER AVENUE <br /> d.. STOCKTON,CALIFORNIA 95202 <br /> �GiRaw <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS SURVEY FORM <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. / Q <br /> Business Name: C v 1G 0 L rw- <br /> Business <br /> Owner(s)Name:: j x) / C a ('Z 19AAV wu /( elephone: / .1?0 <br /> Business Address: ldv? ���C- �/ /LD ' !/r✓ L G/�r��/L1� 9&17 � <br /> Mailing Address(if different from above): G `' J� /L 2/—L Cly 7 <br /> Nature of Business: P Ip .✓I-141-'/M Fire District: Z'S <br /> Ql. IOes LINO 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? <br /> If "Yes",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 /> ❑ B. This business is a health care facility (doctor,dentist,veterinary,etc.)and uses villy 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. CYes XIo Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. Dyes vIo 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 /> V�� rJ <br /> 6 il/G Date 0 �frJ <br /> nt Name <br /> Y Title �U/JTi1v f C C'I2 <br /> Signature (Rev 10196) <br /> 7 <br />