COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

RECEIVED DEC 18 2008 1 SAN JOAQUIN COUNTY �44!n COUNTY OF SAN JOAQUIN OFFICE OF EMERGENCY SERVICES t A� OFFICE OF EMERGENCY SERVICES RONALD R.nALtlWIN ROOM 610,COURMOUSP, COORDI nlna 222 WST WESERAVENUE STOCICTON,CALIFORNIA 95202 TMZPHONE(209)4011.3962 HA,ARDOUS MATS ALS DIVISION(L(!9).468-3969 HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the information on the reverse side before completing this survey form- A separate survey for each business name and/or address in San Joaquin County is required. Business Name: Walgreens#10454 ^ Business Owner(s)Name: Walgreens Corporation Telephone: (209)825-5481 1071 N Main St Business Address: Mailing Address(if different from above): 3E Company,clo Regulatory Department, 1905 Aston Ave,Carlsbad,CA 92008 Nature of Business: Drugstores&Proprietary Stores, Photo-finishing Laboratories Fire District: Manteca Fire Department Q I. MYes ONO Does your business handle a hazardous material in any quantity at any one time in the year? Sex:the definition of hazardous material on the back of this fora,. If your answer is"No",go to Question 4. Q2. ❑Ycs MNo IN=your business handle a hamidous/material,or a mixture containing a hazardous material,in a quantity equal to Or greater than 55 gallons,500 pounds,or 200 cubic fat at any one time in the year? 'Refrigerant exempt,helium<1,200 tuft. If"Yes",how long have you handled these materials at your business? N/A If "Yes",check any of the following conditions that applies to your business? El A- 'Che hazardous/materials handled by this business is contained solely in a consumer product packaged for direct distribution to,and use by,the general public. ❑B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses Qulr y medical gases. ❑C. This business operates a farm for pnrpn.gm of cultivating the soil.raising,or harvesting an agricultural or horticultural commodity, Q3. ❑Vex EING Does your business handle an Acutely Hazanlous Material? See definition on reverse side of this form. Q4. ❑Yes .17No is your business within 1,000 feet of the cuter boundary of a school(grades K-12)? I have read the inforr=lon on this form and understand my requirements under Chapter 6.95 of the California Health and Safety Code. I understand that if I own a facility or property that is used by tenants,that it is my resV)nsibility to notify the tenants of 04e requiteruuuW which crust be net prior to issuance cf a Ccrtirrcatc of Occupamy ur beginning of operations. I declare umL:r the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owner or Authorimd Agent: X Sean Nix,Agent for Walgreens Corporation Date ro Print Name Title Associate Regulatory Specialist,3E Company Signature (Rev 10/96)