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COUNTY OF SAN JOAQUIN <br />'O. OFFICE OF EMERGENCY SERVICES <br />RONALD E. BALDWIN <br />r Room 610, Courthouse <br />DIRECTOR OF <br />222 East Weber Avenue <br />EMERGENCY OPERATIONS <br />Stockton, California 95202 <br />VED <br />Telephone (209) 468-3962 <br />Hazardous Materials Division (209) 468-3969 <br />© 2097 <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />EfV1f1I�Qp'. ,,_ iT41 !!EALTw <br />Please read the information on the reverse side before completing this survey form. A separate survey <br />p�;� <br />for each business name <br />and/or address in San Joaquin County is required. <br />Business Name: «icfiaei ;avid .iiaeri <br />1) ' d 'orene l_ hilii-r,s `Ty-usi <br />Business Owner(s) Name: Telephone: <br />2 a_ r;; <br />0,, �- -?i <br />450, rest lii4,hway 1`< Lodi �A 0{9' <br />8 <br />Business Address: �" � � . �� <br />Mailing Address (if different from above): s P -me <br />Nature of Business: 'iine'ry Fire District: jQQdbridr•a <br />Ql. )�es ONo Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br />/ of hazardous material on the back of this form. If your answer is No," go to Question 4. <br />Q2. Wes ONo Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br />equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at any one time in the year? <br />If "Yes," how long have you handled these materials at your business?) A" <br />If "Yes," check any of the following conditions that applies to your business. <br />OA. The hazardous materials handled by this business is contained solely in a consumer product, packaged for direct <br />distribution to, and use by, the general public. <br />OB. This business is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical gasses. <br />OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br />horticultural commodity. <br />Q3. Mies ONo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br />Q4. OYes QlJo 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 />Owner or Authorized Agent <br />X vir-, 1 <br />Tint Na <br />X <br />Signature <br />F:\Devsys\Planning Application Forms <br />Hazardous Materials Disclosure Survey (Revised 8-25-03) <br />Date: <br />Title: IR 00fi♦! Lk <br />Page 1 of 2 <br />