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Q <br />— SAN JOAOUIN OOUNTY — Fiartnfngt9idg_ Dept <br />OFFICE OF EMERGENCY SERVICES E7Ea Na `'fit X63 = 15 ` <br />Yr HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />PLEASE PRINT OR TYPE <br />01. Please provide a separate survey for each business name and/or address in San Joaquin County: <br />a. Business Name: k1 e- C U N TrtUC.Ic, .�/�� J F -1i z <br />b. Business Owners) Name: �l /� !LIE 17,' 919,'NrcK Phone: <br />C. Facility Address: 3.7 � Co /✓�U 4 r1 <br />d. Mailing Address: 1, .1J E �r4Lrt� r�a c <br />e. Nature of Business: Fire District: <br />I. Business Lic. No: Expires (Moi Standard Indstri Code No: <br />g. Proposed Project: <br />02. Does your business handle a hazardous material? "Hazardous Material- means any material that. because <br />of its quantity, concentration, or physical or chemical characteristics, poses a significant present or potential hazaro <br />to human health and safety or to the environment if released into the workplace or the environment. (Includes fuels, <br />petroleum products, paints, propane, oxygen, ammonia (EHS), chlorine (EHS), pesticides, fertilizers, and hazardous <br />wastes...). <br />Yes til No ❑ <br />03. If you answered 'YES' to Question 2 above: Do you handle a hazardous material or a mixture containing a <br />hazardous material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time? <br />Yes ❑ No E <br />04. Will the owner, applicant, or future building occupant handle an Acutely Hazardous Material? (List of Acutely <br />Hazardous Matenais available at the Planning Department). <br />Yes ❑ No ❑- <br />05. Will proposed building or modified facility be within 1,000 feet of the outer boundary of a school (grades K•12)? <br />Yes F-1No❑ <br />i have read the Hazardous Materials information Guide (on back page) and understand my requirements under Chapter <br />6.95 of the California Health and Safety Code Sections 25505, 25533, and 25534. 1 understand that it the building does <br />nor currency have a tenant that it is my responsibility to notify the occupant of the requirements which must be met <br />prior m issuance of a Certificate of Occupancy. I declare under the penalty of perjury that this disclosure survey is <br />true and accurate to the best of my knowledge and is made in the City of ; > c -c ri-7 -,v California <br />Owner or Authorized Agent: ` <br />(PanRt)fJ2�/til �c L TWO <br />Signature) <br />Sen Joaquin Air Pollution Control DleMcr 3. <br />2021 At Washington St., Suite t <br />Stockton, CA 95203 (209) 4693470 �'y I `� tom• <br />"JAQUIN COUN IY <br />1_'LtIAERGENCYS8] <br />Due /— / % e;5 i. <br />Office of Emergency Servlu■ <br />Haxardoua UaterleLe Dlvlalan <br />222 E_ Weber Ave— dour OUSA-Ain 610 <br />Stockton, CAI <br />202 (209) 4581 <br />OEs tNSP ft"- DtCTE/Zai <br />APPROVE REJECT _ VERI ED _ <br />HUMP _ RUPP _ EXEMPT V.S.0192 <br />