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COUNTY OF SAN JOAQUIN <br /> cPo OFFICE OF EMERGENCY SERVICES RONALD I-BALDWIN <br /> ROOM 610,COURTHOUSE COORDINATOR <br /> 2 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> �c,rtdd TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY S h� <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. QL'7 L l/t <br /> Business Name: �AG r�G/f CLAS <br /> Business Owner(s)Name: , �, t� TelephonneWJ\D�4`� <br /> Business Address: N— '�` L vim' ICA 1 <br /> Mailing Address(if different from above): Z4`5 L4 q1¢IST �� <br /> Nature of Business: -QA5tXT i L*— ?J'Rk-1 L 0�1 L 1 Tit — Fire District: <br /> Ql. Wes 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. es ONO Does your business handle a hazardous material,or a mixture containing a hazardous material,in a <br /> xquantity 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 /> 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 only medical gases. <br /> O C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes Oqo Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes VNo 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 /> of perjury that the information provided on this disclosure survey is we and accurate to the best of my knowledge. <br /> O ner or uthorized Agent:^ I lu <br /> X7 ►�l � Date <br /> Print Name r <br /> Title <br /> nature <br /> �w Z <br /> 57- <br /> 7 <br /> Thursday, October 20, 2005.max <br />