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•o PA. Is$*188 <br />OF 8AN UIN <br />OFF COEUOF EMERGENCY RVICRECEI 1t E® <br />aP4Y.ty, <br />2' Room 610, Courthouse <br />w' <br />222 East Weber Avenue OCT 28 <br />Stockton, California 95202 <br />Telephone (209) 468-3962 ENVIRONMENTAL <br />Hazardous Materials Division (209) 468-39ffiALTH DEPARTMENT <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY 50/Ac <br />Please read the information on the reverse side before completing this survey form. A separate survey for each business <br />name and/or address in San Joaquin County is required. <br />Business Name: Odyssey Environmental Services <br />Business Owner(s) Name: Martin Gates Telephone: (209) 369-6197 <br />Business Address: 5400 W. Highway 12 Lodi, CA 95242 <br />Mailing Address (if different from above): <br />Nature of Business: Construction Services / Truck Terminal Fire District: Woodbridge <br />Q1. Ln es ❑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. 13 es ❑No 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 200cubic 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, <br />packaged for 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 />❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br />agricultural or horticultural commodity. <br />03. ❑Yes ❑tqo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br />Q4. ❑Yes ONo 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 undo eta., ,.., . unuer Chapter 6.95 of the California Health and <br />Safety Code. I understand that if I own a facility or property that is used by tenants, that it is my responsibility to notify the <br />tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I <br />declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best <br />of my knowledge. <br />Owner or Authorized Agent: A4007J�t/ (�•K S <br />X -Wxt� g� - <br />X 'G�NaI`Gic <br />Signature <br />Date: f,4-- /-5 <br />F:\DEVSVC\Planning Application Fonns\Use Permit. (Revised M13-04) Page 6 of 9 <br />