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RECEIVRn <br /> JUL - 8 2008 <br /> COUNTY OF SAN JOAQUIN BHN JUHUUIN UUUN I Y <br /> Pqu N, CRaCECFENlER6ENCYSERVICES <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> ROOM 610,COURTHOUSE COORDINATOR <br /> b: :K <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <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 <br /> is required. // <br /> Business Name: (JJ,//+ L �/ CJ��D//�f U G ezc:2✓1 c �j <br /> Business Owner(s)Name: T�LL/J c `Y2� Telephone: 40-L 37 d el3 <br /> Business Address: Q� ��//SL <br /> Mailing Address (if different from above): /g,) /J�� r-jo <br /> Nature of Business: G/�Y -::r- Z /Al/W/O, District: <br /> Q 1. .Yes ONO 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. es CINo 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 mat _ <br /> If "Yes",check any of the following condition M5 Stockton <br /> CITY OF STOCKTON tea! <br /> 11Jm <br /> A. The hazardous materials handled by this bn5lne, REDEVELOPMENT DEPARTMENT I I I I I® <br /> direct distribution to, and use by,the general pi HAROLD HOLLAND <br /> PROJECT MANAGER 11 <br /> ❑ B. This business is a health care facility (doctor,d <br /> N.EI St.,Room 317 <br /> Stockton, <br /> CA 952 <br /> Stockton,CA 95202-1997 DEPT.(209)937-8538 <br /> www.stocktonggovxom DESK(209)937-8303 <br /> El C. This business operates a farm for purposes Of'I E-mail:hamId.hoEand®dstmkton.ca.us FAX(209)937-5099 <br /> agricultural or horticultural commodity. <br /> Q3. DYes -IW o Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑YesQo 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 /> X 144reld ✓ Date b <br /> Print me <br /> x Title <br /> Signature (Rev 6) <br />