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r <br /> op4H'" c COUNTY OF SAN JOAQUI N <br /> �. .o <br /> OFFICE <br /> OMoc RVICES RONALD E.BALDWIN <br /> ROOM ouRTrvsE222 EAST WEBER AVENUE RECb <br /> • r.. ` F• STOCKTON, CALIFORNIA 95202 <br /> TELEPHONE(209) 62 AUG — 5 2008 <br /> HAZARDOUS MATERIALS DIVISIONISION(209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURV�gyySAN JOAQUINCOUNTY <br /> OFFlCE OF EMERGENCY SERVICES <br /> Please read the information on the reverse side before completing this survey forth. A separate survey for each business name <br /> and/or address in San Joaquin County is required. <br /> Business Name: G(T'z Bjr� sjdc/ 7oY✓ <br /> Business Owner(s)Name: Telephone: <br /> Business Address: 5z � G!✓lG cBi✓ //�U11 MfJ P•2/a'l ¢�H �L, /Z T�M✓ f l+t/? <br /> Mailing Address(if different from above): <br /> Nature of Business: 11- 044/ tC4le G.D_ S Fire District: <br /> Q 1. []Yes N To 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. Eyes t do 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 /> O 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 /> O B. This business is a health care facility (doctor,dentist,veterinary,etc.)and uses only medical gases. <br /> G1 C. This business operates a farm for purposes of cultivating the soil,raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes XO Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Is your business within 1000 feet of the outer boundary of a school (grades K-12)? <br /> Q4. ElYes ko <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 /> x Date <br /> Print Name <br /> g Title <br /> Signature (Rev 10/96) <br />