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4L, COUNTY OF SAN JOAQUIN <br /> pgUlN <br /> �o.• "_ .co` OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> r.' c <br /> ROOM 61Q COURTHOUSE D <br /> a: < <br /> 222 EAST WEBER AVENUE C�Y <br /> • c�.,,.. . „��i•• STOCKTON, CALIFORNIA 95202 MAY -7 2003 <br /> <iFoa TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 UNJOAPUNCOul�7Y <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY':02' ” <br /> - ' E" SERM <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business name <br /> and/or address in San Joaquin County is required.I' <br /> Business Name: c61M1l('g�-}- I/4M S�h�( <br /> Business Owner(s)Name: CoM^CCas: cupGi4.�ow (�l JTelephone: d �� <br /> Business Address: (v7 W Tar" US�nr, e_-c D� y I0e�T0 � <br /> Mailing Address(if different from above): g0 p- eC C. ' L Cv i of 55-6r/c <br /> Nature of Business: le�e.Cr. I, aPx1Q4. r V1iIrnl Ja U-e Fire District: <br /> Ql. )OYes ONO 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. 5fYes LINO 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 is a health care facility(doctor,dentist,veterinary,etc.)and uses grily 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 /> Q3. ❑Yes �No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑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 SYS-A-3 <br /> m Name p <br /> X Title o <br /> Signature (Rev 4/99) <br />