Laserfiche WebLink
n <br /> 1 .. RECEIVED <br /> VIP <br /> k OCT 2 2007 <br /> rLA <br /> OFF SAN JUAIUIN COUNTY <br /> \ fCE OF EMERGENCY SERVICER <br /> / r h „1' <br /> CIDUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610,Courthouse <br /> 222 East Weber Avenue <br /> Stockton,California 95202 <br /> Telephone(209)468-8962 <br /> Hazardous Materials Division(209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> I, <br /> Ploase read the Information on the reverse side before completing tris survey form. A separate survey for each business name <br /> ondlor address in San Joaquin County is inquired. <br /> Business <br /> ,,�1 r rl Q Telephone: <br /> Business owner(s)Nome: rx-P-�L4 � — <br /> 13usin9ss Address, «57M <br /> Mailing Address Of different from,above): l G ��NW —r–�J <br /> Natureorsuslness;g � 'I'JA I � 076 FiroOisfrtct' ; <br /> al Ayes 0 No Doeq your buslnM hnndin a hazardoUs material in any quantity at anyone time in the year. Seethe <br /> C definition of hazardous material on the back of this form. If your answer Is"No,!ego to Q.uesdon 4. <br /> p2. KYes 0 No Does your business handle a hazardous material,or o mixture containing a haz2rd0us mafPrfai in a quantity <br /> equal to or greater than 55 gallons,500 pounds.or 200c any one time In the year? <br /> if,Yes,"how long have you handled"these materials at your business?_ <br /> If Myr"check any of the following conditions that appty to your business. t <br /> 1d(� Tha hazardous.materials handled by this huslhass I%contained solely in a corisurver product,pwkaged for <br /> dkect distribution to,and use by,the general pubrie. <br /> 0a. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses oob(medical gases. <br /> ©C. Tlils business operates a farm for purposes of cultivating the soil,raislrl,or harvagtinq an agricultural or <br /> horticulturai r business handle an arutety ha7r rt] t;9 Commodity. <br /> i <br /> Q Byes No Dari you malt See definition on r$verse. side of this form. <br /> �_ ou <br /> Is your txasiness within 1,000 t of the outer boundary of a school(g rades K 12)9 <br /> Q4. Dyes I <br /> I-have <br /> IrunerO under-Chapter 6.95 of the California Health and$afety <br /> Code.read the informationfon this kxrrn and underfiy thand t Is used h tenants,that it Is my mponsibility 10 noUry the tenants of the <br /> Coda. I understand that If i own a faciraY or proper y <br /> requirements which must be met prior to issuance of a CortlAcate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the Information provided on this disdosure survey is true and eccursW to the bort of my knowledge. <br /> owner or Authorized Agent ) <br /> x �_ Date: <br /> x <br /> na e <br /> Pang d rif S <br /> PAGE 212"RCVD AT 91211200712;00,27 PM Pacific Daylight Time] SVR,RIGHTFAXII x DNISA�CSID; DURATION(mm-sS);0142 <br />