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r <br /> e' <br /> 'COUNTY OF SAN JOAQUIN. <br /> ,OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 EasfWeber Avenue <br /> Stockton, California 95202 <br /> Telephone J209)468-3962 <br /> Hazardous Materials Division (209)468-3969 <br /> HAZARDOUS MATE=RIALS 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 is required. ` <br /> Business Name: <br /> . Business Owner(s)Name: Telephone: , <br /> Business Address: <br /> Mailing Address(if different from above): <br /> Nature of Business: Fire District: <br /> 01. ❑Yes No Does your business handle a hazardous material in any quantity at any one time in the <br /> year? Seethe definition of hazardous material on the back of this form. If your answer is <br /> No,'go to Question 4. <br /> 02. Oyes No Does your business handle a hazardous material,or a mixture containing a hazardous <br /> material In a quantity equal to or greater than 55 gallons,500 pounds, or 200cublc feel at <br /> any one time In the year? <br /> F If"Yes,"how long have you handled these materials at your business? <br /> s <br /> If"Yes,"check any of the following conditions that applies to your business, <br /> ❑A. 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 ony 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. ❑Yes 0 Does your business handle an acuteiV__hazardous material? See definition on reverse <br /> side of this form, - p <br /> 04. 13Yes GMI'o Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? F <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 1s 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 <br /> my knowledge. that the information provided on this disclosure survey is true and accurate to the best of <br /> Owner or Authorized Agent: . <br /> POLOI,ef( <br /> X 1-vP <br /> Print <br /> X ee `,k- I <br /> Signature <br /> I <br />�. _�.. �,-�.}.�lruww._'Mali'z^�.r•+�'nG�" ., +h.yt;...�_-.�•. __ae <br /> I <br />