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I f:• :.4 i i Erb a COUNTY OF SAN JOAQUiN OFFICE OF EMERGENCY SERVICES 1 Room 610, Courthouse 222 East'Weber Avenue Stockton' California 95202 Fele hone 209)468-3962 Hazardous Materials Division (209)468-3969 HAZARDOUb MATERIALS DISCLOSURE SURVEY I Please read the Information on the reverse side Before completing this survey form. A separate survey for each business ` I name and/or address in San Joaquin County Is r i quired. Business Name: C C A Business Owner(s) Name: Telephone: 9� $51-- 1306 , Business Address: 01 :21 LANG lg /- E5 icy Mailing Address(if different from above): XXI0(o . 1g Uq c- �f}4/&A, t S 5 10 A) Fire District: R1PCW /fU'z�`1_ I Nature of Business: Q1. )dYes © No Does your business handle a hazardous material in any quantity at any one time In the year? See the definition of hazardous material on the back of this form. If your answer is No;go to Question 4. Q2. Dyes 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 200cuble feet at any one time in the year? If"Yes,'how long have you handled these materials at your business? It"Yes;check any of the following conditions that applies to your business. I 13A. 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. IDB. This business Is a health care facility(doctor,dentist,veterinary,etc.)and uses only medical gases, 13C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or horticultural commodity. 03. MYes ;dNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. Q4. ©Yes XNo Is your business within 9,000 feet of the outer boundary of a school (grades K-12)? I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and 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 tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations, I declare under the penalty of perjury that the information provided on this disclosure survey Is true and accurate to the best of my knowledge. Owner or Authorized Agent: E X Date: I In a ,�1 Title: _ _/06&/is� _ i Signature i i I� I I I