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RECEIVED <br /> NOV 2 0 M <br /> COUNTY OF SAN JOAQUIN 5A11 111A11N 2UNTY <br /> OFFICE OF EMERGENCY SERVICES OFFICE OF ENERG✓rNCY SERVICES <br /> Room 610, Courthouse <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 is required. <br /> Business Name: -RWEU-Gds <br /> ( b9 'S3y-73Z! <br /> Business Owners)Name: F 1�/ CL�4S Telephone:_ <br /> Business Address: 12—"1 S C4 ?s-.7 c� <br /> Mailing Address(if different from above): E0�� <br /> Nature of Business:�+�P E CYW''' '11-(791 TyWJ Fire District: <br /> Q1. &Yes ❑ No Does your business handle a hazardous material in any quantity at any onej#ime 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. Yes ❑ No Does your business handle a hazardous material, or a mixture containing a{hazardous material in a quantity <br /> equal to or greater than 55 gallons, 500 pounds, or 200c any one time in#/h�e'py.ear-7 <br /> If"Yes,"how long have you handled these materials at your business? Y✓�a y� _ <br /> If"Yes,"check any of the following conditions that apply to your business. <br /> � <br /> 1(A. The hazardous materials handled by this business is contained solely in a consumer product, packaged for <br /> l direct distribution to, and use by, the general public. <br /> ❑B. This business is a health care facility(doctor, dentist,veterinary, etc.)and uses only medical gases. <br /> 11 C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3. []Yes KNo Does your business handle an acutely hazardousmaterial? See definition on reverse side of this form. <br /> Q4. []Yes ' No 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 Califomia 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 the <br /> 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 • -�oa}rZ C�rL� Date. <br /> Prirra <br /> X Title:_ <br /> Signature <br /> F-RI III f)wl:Yi.nliM1 f'R�FRufT COP_[XIYMFRf:IAI !1!S!R'vacnA M1.'114IIT ' Pane 4 of 5 <br /> E <br />