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0 <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD BALDWIN <br /> ` �a _ . 2101 EAST EARHART AVENUE SUITE 300 DIRECTOR of <br /> -: �. <br /> STOCKTON,CALIFORNIA 95206 EMERGF� fY OPERATIONS <br /> TELEPHONE(209)953-6200 ���! <br /> FACSIMILE(209)953-6268 IED <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY DEC 2 3 2UQg <br /> Please read the information on the reverse side before completing this survey form. A seD6 ch <br /> business name and/or address in San Joaquin County is required. OFENIERbi L'N7Y <br /> / p cYst�VICES <br /> Business Name: A Inf�c1 t°�?fY� $"� 5 5 <br /> Telephone: -�d� g3 /' ooZ <br /> Business Site Address: -i2 S Pr6tvr D k, 5r4 c200 GCq <br /> Mailing Address (if different, CJS '�from above): f 2� <br /> Business Owner(s)Name: 6ba! r�iaS Xr# ' <br /> �4- elephone: 31 D- S 30-A22o <br /> Business OwnerAddress:� j W /.o to&q, 1310, r>y-r cky%ce. , C 4t 10570S <br /> Nature of Business D!S41 her 7 ?VA UG V--e—kyta 5e-, Fire District: <br /> QL ®Yes ❑No Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on the back of this form. If your answer is"No",go to Question 4. <br /> Q2. D4Yes ❑No Does your business handle a hazardous material,or a mixture containing a hazardous <br /> material,in a 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 this site? <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 <br /> packaged for direct distribution to,and use by,the general public. <br /> ❑ B. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. Eyes [:]No Does your business handle an Acutely Hazardous Material? See definition on reverse side <br /> Q4. []Yes DqNo 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 <br /> Health and Safety Code. I understand that if I own a facility or property that is used by tenants,that it is my <br /> responsibility to notify the tenants of the requirements which must be met prior to issuance of a Certificate of <br /> Occupancy or beginning of operations. I declare under the penalty of perjury that the information provided on this <br /> disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> Date <br /> X Title <br /> Signature (Rev 10/08) <br />