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COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />2101 E. Earhart Avenue, Suite 300 <br />STOCKTON, CA 95206 <br />TELEPHONE (209) 953-6200 <br />FAX: (209) 953-6268 <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 and/or <br />address in San Joaquin County is required. `� C2 / v <br />Business Name: Telephone: `1 ' - ✓ 66 ,✓ Z2,2, <br />�Business Site Address: CSS <br />Mailing Address (if different from above):` ��✓' �� f--��-1 L��� <br />Business Owner(s) Name: `��G W Te <br />Business Owner Address: 1&�e6g)&� Pk <br />/y� �l1Jr ,UC District: L9� <�'�'T/vs'U�I�ife <br />Nature of Business: `D �a � G� G° ' <br />Q1. ,Fzes ❑No Does your business handle a hazardous material in any quantity at any one time in the year? See the <br />�No <br />definition of hazardous material on the back of this form. If your answer is "No", go to Question 4. <br />Q2. [:]Yes 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 />❑ 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 Oo Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br />Q4. ❑Yes�Io 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 the <br />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 />nr Authorized Aeent: <br />Signature <br />Title <br />(17/)0 <br />10 <br />(Rev 8/08) <br />