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COUNTY OF SAN JOAQUIN <br /> r. OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse RECEIVED <br /> 222 East Weber Avenue <br /> • �4YlFoaN�P• Stockton, California 95202 NOV 17 AIM <br /> Telephone(209)468-3962 <br /> Hazardous Materials Division (209)468-39 SAN <br /> Of EMERGENCY SERVICE <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 <br /> name and/or address in San Joaquin County isrrequired. <br /> ,, <br /> Business Name: 1 F'1 MOSS Mt1+'J *t&k <br /> Business Owner(s) Name: L H- VOSS Telephone: qg5-6110Z91© <br /> Business Address: 3030 S. 1-EW4• 99Jl7�V CSY\ rfic <br /> Mailing Address (if different from above): a9�Syl r,+p - .Del Kil ConCOrcl CA g4Sa o <br /> WA <br /> �.(>il K.(, <br /> Nature of Business: S I(� Fire District: <br /> Q1. ❑Yes *o Does your business handle a zardous 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. OYes ONo 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 /> OA. 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 /> OB. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses onlv medical gases. <br /> OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes ONo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes ro 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 <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: <br /> X L.1F. 1�iSS Date: /o -6t3 -Oce <br /> rant ame <br /> X p _�/ Title: TW(da t <br /> Signature <br /> F:\DevSvc\Planning Application Forms\Business License(Revised 08-30-06) Page 4 of 7 <br />