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9 <br /> e6RECEIVED' <br /> ► City Bldg Dept <br /> e <br /> � Application# <br /> COUNTY OF SAN JOAQUIN ROINVIRON <br /> �qu•th.\'�'� C00121j'fi�tii 1 �Dq -rJ -r <br /> o.••• c., �., - OFFICE OF EMERGENCY SERVICES n <br /> � •� <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 - <br /> TELEPHONE(209)46$-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS SURVEY FORM do <br /> Please read the information on the reverse,side before completing this survey form. A separate survey for each <br /> business name and/or address in San Joaquin County is required. <br /> Business Name: Restaurant Technologies, Inc. <br /> Business Owner(s)Name: Scott Streetman-Corporate Field Services Telephone: 612-803-8599 <br /> Business Address: 3840 Metro Drive, Stockton, CA 95203 <br /> Mailing Address (if different from above): 2250 Pilot Knob Road, Suite 100; Mendota Heights, MN 55120 Q_A)p Q,lac t <br /> Nature of Business: Storage and distribution of cooking oil Fire District: <br /> Q1. ©Yes ❑No 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, Q Yes ❑No Does your business handle a hazardous material,or a in ixture containing a hazardous material,in a quantity <br /> 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 /> ❑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 /> ❑B. This business is a health care facility(doctor,dentist,veterinary;etc.)and uses only medical gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity <br /> QS. ❑Yes No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4., ❑Yes ❑No Is your business within 1,000 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 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 t [ /�S Date 6 / <br /> Print te <br /> Date /. <br /> Sig at re <br /> i <br />