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0 <br />0°4uIN c <br />4 <iFpR� <br />COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />Room 610, Courthouse <br />222 East Weber Avenue <br />Stockton, California 95202 <br />Telephone (209) 468-3962 <br />Hazardous Materials Division (209) 468-3969 <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />RECEIVEC <br />SEP 15 2007 <br />OFFICE OF EMERGENCY SERVICES <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: LcD 64.s Src2o-&� <br />() LzO: C,06 97CAAC-u Tele �� —�27 / l STT, <br />Business Owners Name: phone: �L -r( �o � <br />itx7 r 1. <br />Business Address: &32 �S N • S•T a -j- 95 <br />Mailing Address (if different from above): <br />Nature of Business: (-SAS S(rn� Fire District: <br />es O 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. >ZlYes O 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 the year? <br />i <br />If "Yes," how long have you handled these materials at your business? Serfs <br />If "Yes; check any of the following conditions that apply to your business. <br />OA. 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 />OB. This business is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical gases. <br />OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br />horticultural commodity. <br />Q3. >i <br />