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EHD Program Facility Records by Street Name
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1900 - Hazardous Materials Program
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PR0520764
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COMPLIANCE INFO
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Last modified
12/5/2018 2:07:53 PM
Creation date
9/10/2018 11:23:15 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1900 - Hazardous Materials Program
File Section
COMPLIANCE INFO
RECORD_ID
PR0520764
PE
1919
FACILITY_ID
FA0001655
FACILITY_NAME
RED LOBSTER RESTAURANT #381
STREET_NUMBER
2283
Direction
W
STREET_NAME
MARCH
STREET_TYPE
LN
City
STOCKTON
Zip
95207
APN
11222023
CURRENT_STATUS
01
SITE_LOCATION
2283 W MARCH LN
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
Scanner
JCastaneda
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EHD - Public
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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES N <br /> ,�; •. ROOM 610,COURTHOUSE a*14=71 <br /> 222 EAST WEBER AVENUE <br /> •'r Htw STOCKTON,CALIFORNIA 95202 SAN JOAQUIN COUNTY <br /> tifbk <br /> TELEPHONE(209)468-3962 OMCE OF EMERGENCY SERVICES <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <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 name <br /> and/or address in San Joaquin County is required. <br /> Business Name: QEO (F65PtZ 2tT5(A{2AA7k_ <br /> Business Owner(s)Name: DARbEA.) Q>aSTAL4?A/S51/JG Telephone: C7Z) 427 •$W-7 I <br /> Business Address: 22'53 0 , MAOC(-1 (AAA-- I S-mnano (?A <br /> Mailing Address(if different from above): <br /> Nature ofXes <br /> Businrquantity <br /> I LY- 1S_(-t/CF- i2ES'I A02,A"T Fire District: S 0 TG�J <br /> Q 1. business handle a hazardous material in any quantity at any one time in the year? See the <br /> of hazardous material on the back of this form. If your answer is"No",go to Question 4. <br /> Q2. s business handle a hazardous material,or a mixture containing a hazardous material,in a <br /> IIqual to or greater than 55 gallons,500 pounds,or 200 cubic feet at any one time in the year? <br /> Pf(00 <br /> VVw Y If"Yes",how long have you handled these materials at your business? <br /> Q,Y <br /> C4, <br /> I Qi Lr S ' If "Yes",check any of the following conditions that applies to your business? <br /> 1" <br /> p�a•v <br /> e v ❑ A. The hazardous materials handled by this business is contained solely in a consumer product packaged for <br /> Y oo • direct distribution to,and use by,the general public. <br /> Zo <br /> LI L y I ❑ B. . This business is a health care facility(doctor,dentist,veterinary,etc.)and uses Qlijyy 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 7-INo 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 /> 1 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 S-M-QE bate I - 13 -00 <br /> �•��� Print Name p <br /> X r " Title C,J} AeeS Ft�'1eyi+ <br /> Signature (Rev 10/96) <br />
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