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04/30/2010 12:24 4699165375 PAGE 01/01 <br /> APR/29/2010/TRU 09:00 AM 9 <br /> P, 00; <br /> REGEIVED <br /> APR 3 0 2010 <br /> COUNTY OF SAN JOAQUIN SAN JOAQUIN COUNTY <br /> OPFICFOFfiMERGENCYSERVICES a0milar-RAUM OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE COMDDIATml <br /> 722 EAST WEBER AVFJ'JUE <br /> SfOCRTON,CALIFORNIA 95202 <br /> ''-•'!k o TBbkYHONS(209)a6a79�f'1,'5'3-la2 Qb - <br /> HAZhRP4UE.MATERaLS DIVISION.(209)4663964,. . .. _. _. .. ._ ,. _.. <br /> HAZARDOUS MA.TERIAL3 DISCLOAURE SURVEY <br /> Pluse read the information on the reverse aide before completing this survey form. A separate muvey for each business nate <br /> andlor address in San Joaquin County is required- <br /> Business Name: 1 yam. <br /> Business Owners)Namc: 2�nryj � PS't" V,(. C( 1��f�.�.� -Telaphonc: <br /> Business Address: aJ �. r a s_,tru7, Jd��`^`^ "n l ���0� — <br /> Meiling Address(ld different from above): <br /> Nature of Businesst:�L I(I U . Ay _� _____Fire Districrz_,_ <br /> Qt. ayes M/40 Does your business handle s hazardous material in any quantity at any one time in the year? See the <br /> � definition of harrdous material on the back of this from. If your answer is"No",go to Question 4_ <br /> Q2. Oyes WN�o Does your business handles hazardous material,or a mixture containing a hazardous materiel,in a <br /> quantity equal to of greater than 55 pUom,500 pounds,or 200 cubic feet at any one time in the year? <br /> If"Yes",bow long bave you handled these materials at your business? <br /> If ,Yes,,,check any of the folltr nag conditions that applies to your huMness? <br /> O A. The hazardous materials handled by this business ie contained solely in a consunea product packaged for <br /> direct distribution to,and use by,the general public. <br /> D <br /> B. This business is a health tete facility(doctor,dentist,veterinary,etc)and uses QW1 medical gases. <br /> C1 C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes Mlil D Does your business handle an Acutely Hazardous Material? See definition an reverse side of this form. <br /> Q4. LjYm QNo Is your business within 1,000 feet of the outer boundary of a school(grades R-12)? <br /> T have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br /> Code, 1 understand that if I own a facility or property that is used by tenants,that it is my rouponaibility,to notify the.tenants of <br /> the requitaments which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of par)ury that the information provided on this disclosure survey i9 true and aecutate to the best of my knowledge. <br /> Owner of Autborized Agent: <br /> x ' -� Q I- l ata V r <br /> pont Name . 0.9r <br /> R Tide <br /> (Rev 10!96) <br /> -2 1 A11 <br />