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F••2CEivEL) <br /> o)A7 n SEP 200t <br /> "` I JU/iUUIN <br /> OFFICE OF EMERGE <br /> NUCYSUUNI y <br /> EFWES <br /> e COUNTY OF SAN JOAQUIN <br /> 3 „a" • OFFICE OFEMEROENCYSERVICES ttuuwawmnR <br /> i ROOM 510,COURTHOUSE CDMIN 17DIt <br /> 222 EAST LAMER AVENUE <br /> .:.R STOCKTON,CALIFORNIA 95202 <br /> TIMMMONR(209)1683962 <br /> HAZARDOUS WATERIM S DIVISION(209)166.3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse aide before completing Ws survey form. A separate survey for each business name <br /> and/or address in San Joaquin County is required. <br /> Business Nilmo: McDonald' s Restaurant <br /> Business Owners)Name: <br /> McDonald's USA,LLC (Patrick Diffley) Telephone: (9]-6) 591-9352 <br /> BushnesSAddmss: 8020 Lower Sacramento Rd, Stockton, CA 95210 <br /> Mailing Address(if different from above): . <br /> Nature of Business: Fre District: <br /> Ql. OYes MNo Does your business handle a hazardous material in any quantity at my one time in the yea? Sae the <br /> definition of hazardous material on the beck of this form. If your answer is"No go to Question 4. <br /> Q2. Dyes DNo 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 /> D 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 /> D B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses Dilly medical gases. <br /> D C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. DYes ❑No Does your business handle an Acutely Hazardous Material? See definitiomm reveme side of this form. <br /> Q4. C1Yes E1No is your business within 1,000 feet of the outer boundary of a school(grades-K-12)? <br /> 1 have read the information on this form and under mrd 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 time and accomte to the beat of my knowledge. <br /> Owner or Authorized Agent: <br /> g Patrick Diffley ate '(j -7alo—_ <br /> 1, Print Name <br /> �. M <br /> % � Trde.McDonald's Project Manager <br /> Signature (Rev 10196) <br /> Thursday,October 20,2005.max <br />