Laserfiche WebLink
rear io iu uzi: -roa oan uoaquin u [UySosbGtiti p. a <br /> t h COUNTY OF SAN JOAQUIN <br /> h-11;4 OFFICE OF EMERGENCY SERVICES Wa\/ch <br /> ' I 2101 E. Earhart Avenue,Sutte 300 �►GU <br /> STOCKTF(2 CP. 93-6 2 APR a s 20,12 <br /> IN TELEPHONE(209)9:3-6200 74 R <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the infornati on on the reverse side before completin?.his surrey form. A separate survey for each business name ardPor <br /> address in San Joaquin Co(u�nt, is require�d�(� <br /> BusinessN'ame: l ry\ rte an '1 `t tG C4� `I'�G Telephone: A2 <br /> Business Site Address: P�Jv�Ed �"�G 1 C ".- '^�6 — <br /> Mailine Address(if different from above,: <br /> QOM <br /> Business Owner(s)Name: 5,\ Telephone: <br /> Business Owner Address: ---- <br /> Nature of Business: __ Fire District:_ <br /> Oi. K(IYes . io Does vour business handle ahazardous malc ial in any quantity at any one time in Elie year? See the <br /> detinitior. of hazardous material on thO back of this form. if your answer is"\o",go to Question 4. <br /> Q2. j'&es ❑�'o 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 /> rf'•vrc" hnw Im.n have vnu !mand!ed these materials at vour hu.ciness? t— li 9 If <br /> If "Yes",check any of the following conditions that applies to your business? Fine e rvC <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 /> agricu!tural or horticultural commodity. <br /> Q3. ❑Yes ,�o Does your business handle an Acutely Hazardous Mawrial? See definition on reverse side of this form. <br /> Q4. Eyes 'SNo is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> T hav,read rhe infmmatinn on this form a..n.d understand my renuireme-nte under Charter 6 95 of the California Health and Safe:v <br /> Code. I understand that if I own a facility or property that is used by tenants,that it is my responsibilm,to notiy the tenants of the <br /> reouirements which must be met onur to issuance of a Certiticate a Occuoaner or besinring of operations. !.declare under the <br /> penalty of perjury that the intbrmation provided on this disclosure survey is true and accurate to the best of my knowledge, <br /> Owner or Authorized Agent: <br /> X � Date <br /> CName <br /> x rrC ilia t���.c�erl'�"' <br /> (Rev 8/08) <br />