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tM; . COUNTY OF SAN 16)QUIN OFFICE OF EMERGENCY SERVICES Room 610, Courthouse 222 East Weber Avenue PECEIVED Stockton, California 95202 NOV 12 20 Telephone (209)468-3962 �#� 0$ Hazardous Materials Division (209)468-3969 SAN JOAQUIN COUNTY HAZARDOUS MATERIALS DISCLOSURE SURVEY I OFFICE OE EMERGENCY SERVICES Please read the information on the reverse side before completing this survey form. A separatesurveyfor each business name and/or address in San Joaquin County is required. Business Name: —Fr=ak-L-CAs4V A IV 1p"Le 9*lr40 , Business Owner(s) Name: TEILM"rt7 Telephone: 161_ s,o6 Business Address: 1171 S /'7rr"' Ab Mailing Address(if different from above): Nature of Business: (hl A(,a*-e- &YST2I8di7&4&F AN*& 1J (_ ✓bW Fire District: C *rVoP-M)J*'Gtr Q1. OYes ❑No Does your business handle a hazardous material in any quantity at anyone tune in the year? Seethe definition 16 of hazardous material on the back of this form. If your answer is No," go to Question 4. 02. y es ❑No Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at any one time in the year? If"Yes," how long have you handled these materials at your business? of WAI,S If"Yes," check any of the following conditions that applies to your business. ❑A. The hazardous materials handled by this business is contained solely in a consumer product, packaged for direct distribution to, and use by, the general public. a { ❑B. This business is a health care facility(doctor, dentist, veterinary, etc.) and uses only medical gases. ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or horticultural commodity. ) Q3. ❑Yes PNo Does your business handle an acutely hazardous material?: See-definition on reverse side of this.form: - Q4. []Yes l No Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? i I have read the information 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 responsibility to notify the tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of;{operations. I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate toithe best of my knowledge. Owner or Authorized Agent: i X ?,AJmVa-- Date: y�Z IJP r t Name X l Title: �+ FQ� lYi• l1�'foE2� Signature F;10evSv6P1anning Application ForrnMBusiness License(Revised 01-18-08) Page 4 of 8 r