COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

COUNTY OF SAN JOAQUIN m: OFFICE OF EMERGENCY SERVICES RONALD X. BALDWIN Room 610.CouPTMouSE COORDINATOR 222 EAST WEBER AVENUE Cq��FppN�P STOCKTON. CALIFORNIA 95202 - Te .o.[(209)4663962 H. Roous MAnA1ALs OMSION (209)4(563969 HAZARDOUS MATERIALS SURVEY FORM Please read the Hazardous Materials Information Guide on the back side before completing this survey form. A separate form for each business name and/or address in San Joaquin County is required: Business Name: RROAT)RASF INC. dha 7TFFY TTTRF Business Owner(s) Name: Donald W. FQw, er Phone: 209-858-5143 FacilityAddress:1209 E Hammer Lane, Stockton CA 95210 Mailing Address: 4000 W Yosemite Road :E7 Lathrop, CA 95330 Nature of Business: Automotive Quick Lube Fire District: Stockton 01. x7 Yes ❑ No Does your business handle a hazardous material? Read back nage. If you answered "No" to Question 1, go to Question 4. 02. SI Yes ❑ No Does your business handle a 'hazardous material or a mixture containing a hazardous material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time? If you answered "No" to Question 2, go to Question 4. If you answered "Yes" to Question 2, do any of the following statements apply to your business? Read back page. ❑ A. The hazardous materials handled by this business is contained solely in a consumer product packaged for direct distribution to, and use by, the general public. ❑ B. This business operates a health Bare facility (i.e., doctor, dentist, veterinary...) and uses only medical gases. ❑ C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or horticultural commodity. Q3. ❑ Yes IN No This business or building occupant handles an Acutely Hazardous Material? Read back nage. 04. ❑ Yes Q No This facility or modified facility will be within 1,000 feet of the outer boundary of a school (grades K-12). I have read the Hazardous Materials Information Guide and understand my requirements under Chapter 6.95 of the California Health and Safety Code. I understand that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. I declare under the penalty of perjury that this disclosure survey/exemption is true and accurate to the best of my knowledge. Owner or Authorized Agent: X Paul E. Harbott Title General Manaffar Print Stephanie Jack G (\ Custom Service ; X Date �i;2Q r signatu B - - - - -