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dro _ 5070 <br /> �v <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> L, w` ROOM 610,COURTHOUSE - COORDINATOR <br /> 222 EAST WEBER AVENUE RECEIVED <br /> STOCKTON,CALIFORNIA 95202 ^ e� <br /> iio A" TELEPHONE(209)466-3%2 OCT 3 �y�0 LIJ{q <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> FRCE0FEWRGIENCYS RE COUNTY <br /> Please read the information on the reverse side before completing this survey forst. A separate survey for each business name <br /> and/or address in San Joaquin County is required. <br /> t <br /> Business Name: 1GlAC1fLt_ /ADI b 1t Ml✓ G <br /> Business Owner(s)Name: �VVA_dKOt/'�r Telephone,: <br /> Business Address: 10�� _ 1�lkliAlly LJriIIP �T()lJL7�OY� �„� 61�0'f�� <br /> Mailing Address(if different from above) t �/�� �-/�,, /(t �� ✓t (bt/l n �-�"" � <br /> Nature ofBusiness: . oWd waterY✓�G{lilU f�f 4VI-i t-la Fire District: <br /> Ql. IMYes E)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. les ONO 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 feel at any one time in the year?L Z <br /> If"Yes",how long have you handled these materials at your business? a L,�✓�oye,,b�N J///OG <br /> If "Yes",check any of the following conditions that applies to your business? <br /> O 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 /> O B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses g01y medical gases. <br /> O C. This business operates a fart for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. (ROly <br /> yes O_NLOO Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. <br /> yes 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 <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 Date <br /> Print Name <br /> X Tithe SD/• <br /> Signature (Rev 10/96) <br /> Thursday, October 20,2005.max <br />