COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Y .l COUNTY OF SAN JOAQUIN OFFICE OF EMERGENCY SERVICES Room 610, Courthouse 222 East Weber Avenue Stockton, California 95202 JUL 12 2002 Telephone (209) 468-3962 Hazardous Materials Division (209)'468-3969 iFu+ounuUlNuOV)'yyy tFA( 0FEMERGFNCyS%RUICE, HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the Information on the reverse side before completing this survey form. A separate survey for each business name and/or address in San Joaquin County is required. Business Name: L - Business Owner(s) Name: TA 12,qq I Telephone: _ U Business Address: 113 !� �T� "T LL20 � CA a52L�Q 2 c/ Mailing Address(if different from above): Z77,iq m pE: Nature of Buslness: I /�JAC" AI G L 141 K Fire District: E�R-LSU Q1. ;Z''as ONo Does your business handle a hazardous material in any quantity at'a y ale time in the year? Seethe definition of hazardous material on the back of this form. If your answer Is Not'go to Question 4, Q2. )21�es ONo Does your business handle a hazardous material,or a mixture containing a hazardous malarial 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? l If"Yes;check any of the following conditions that applies to your business. OA. 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. OB. This business Is a health care facility(doctor, dentist,veterinary,etc.) and uses only medical cases. OC. This business operates a farm for purposes of cultivating the soil, raising,or harvesting an agricultural or horticultural commodity. Q3. -OYes ONo Does your business handle an acutely hazardous material? See definition on reverse side of this form. Q4. OYes [3No Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? 1 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 to the best of my knowledge. Owner or Authorized Agent: X�E��I QDI I I Date: `4'x2_ X „tie:i=1�s I D EowI= z Igna ure i i