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�n <br /> RECEIVED <br /> P4�tN. COUNTY OF SAN JOAQUIN UIN <br /> OCT 17 2005 <br /> IV <br /> OFFICE OF EMERGENCY SERVICES e �s€r+vlo � <br /> ROOM 610,COURTHOUSE OFF 1REC`OR OP <br /> 222 EAST WEBER AVENUE EMERGENCY OPERATIONS <br /> • c... c STOCKTON,CALIFORNIA 95202 <br /> 4c�F°aa TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <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 <br /> and/or address in San Joaquin County is required. Q <br /> Business Name: t�.4-ca v4/4 iEsi 10 ye z,,- �c. Telephone: 26 2 ' 'fC U 4— 7? <br /> Business Site Address: �� °/ (/ S� 1,7� ;- 2 ( S M-C-,lC l-e ti/ C - C2�S z/15 <br /> Mailing Address(if different from <br /> �adbov,e): ?pp-C 9L) -p .3 0 �f/� S/Z7G K4W� C*- %51/I <br /> Business Owner �' U a s)Name: el � Telephone: 7-01 q/�-a C117 <br /> Business Owner Address: /�;z1FL Lrcel (nAOr- c-i-- 1;711 a!C4 n d 7!5f3,6 <br /> Nature of Business: r7ldaa i LL-L4 Fire District: /27 0-4L <br /> Ql. Wes ❑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. []Yes ESKo Does your business handle a hazardous material,or a mixture containing a hazardous material,in a <br /> quantity 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 this site? <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 operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes ®No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes J�ONo 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 <br /> the 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 L 1 U -1./ir— Date <br /> X <br /> A- Print Name <br /> � � Title <br /> Signature (Rev 3/05) <br />