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0 <br />0 <br />eiN COUNTY OF SAN JOA UIN 0--jqq <br />OFFICE OF EMERGENCY SERVICES RONALD E, BALDWIN <br />-' ROOM 610, COURTHOUSE COORDINATOR <br />b: K <br />,,.�*., p. A�tr • e'i{ 222 EAST WEBER AVENUE STOCKTON, CALIFORNIA 95202 <br />RECEIVED <br />'4 <br />TELEPHONE (209) 468-3%2 <br />`1 HAZARDOUS MATERIALS DIVISION (209) 468-3%9 DEC 0 6 2012 <br />AZARDOUS MATERIALS DISCLOSURE SURVEY ENVIRONA <br />ALPlease read the information on the reverse side before completing this survey form. A separate survey for cF�fl4d'lir@MftlENT <br />and/or address in San Joaquin County is required. <br />Business Name: <br />Business Owner(s) Name: <br />Business Address: <br />Mailing Address (if different from above): <br />Telephone: <br />Nature of Business: 294 Fire District: <br />Q 1. 0Yes V(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. Oyes FlNo 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 your business? <br />/ If "Yes", check any of the following conditions that applies to your business? <br />IBJ 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 is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical gases. <br />EIC. This business operates a fart for purposes of cultivating the soil, raising, or harvesting an <br />agricultural or horticultural commodity. <br />Q3. OYes 7SO Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br />Q4. OYes 23 o 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 />All <br />TIM U112 <br />An <br />Elk', . I <br />