Laserfiche WebLink
CRL-SIERRA_P_IPE INC Eax:209-4613-671 �_ Dec 22 2010 11:13am�P002/002 <br /> • <br /> • i <br /> COUNT'S( OF SAN JOAQUIN RECEIVE <br /> OFFICE OF EWRGENCY SERVICES <br /> 1 2101 E. Earhart Avenue,Suite 300 DEC 2 2 2010 <br /> STOCKTON,CA 95202 <br /> `r.•� TELEPHONE(209)953-6200 <br /> SAN JOAQUIN COON <br /> OFFICE OF EMERGENCY Ty <br /> �RICES <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 andlor <br /> address in San Joaquin County is required. <br /> Business Name:�f}f-'Sft_—�+Z� TPL r <br /> Business Site Address: ,�� _i-1 S.'.y L✓4Y Q�r �!['Y'K�n r �', �( <br /> Mailing Address(if dilltmitt from above): r. <br /> Business Owners)Name:. 4� L l Telephone: �4����-�t� <br /> Business Owner Address: 1�rr. 1`'i�� '�• ra Q~ 7�5�4..i� <br /> Nature of Business: ,�i(=1=�:'�1P�= e/f<-hFite District: r/y <br /> Ql. fiaYes Flo Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material ori the back of this form- If your answer is"too",go to Question 4. <br /> Q2. ®r Yes ❑No Does your business handle a hazardous material,or a mixture containing a haurdoua material,in a <br /> quantity equal to or greater than 55 gallons,500 pounds,or 200 cubic fees at any one time in the year? <br /> If"Yee',how long have you handled these materials at your business? �iN �' f 96p21 <br /> If "Yes",check anv 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 operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. Oyes .2Ao Does your business handle an Acutely Hamrdous Material? See definition on reverse side of this form. <br /> Q4. 12yes Al—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 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 t5c <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 /> Owncr or Authorized Agent: <br /> n ;1 t� <br /> f . l t Date <br /> / P n;Nan <br /> X <br /> / ignature <br /> (Rev 8/08) <br />