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E � I COUNTY OF SAN JOAQUIN OFFICE OF EMERGENCY SERVICES Room 610, Courthouse 222 East'Weber Avenue ,Stockton, California 95202 Telephone J209)468-3962 Hazardous Materials Division (209)468-3969 HAZARDOUS MATERIALS DISCLOSURE SURVEY I Please read the information on the reverse side Before completing this survey form, A separate survey for each business name and/or address in San Joaquin County is r quired. Business Name:. ! Business Owner(s)Name: Telephone: Business Address: I GL KI, ( 5 S aS } C ` I Mailing Address(if different from above): f Nature of Business: Fire District: 01. ❑Yes 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 t No,"go to Question 4. 02. ❑Yes dNo Does your buslness handle a hazardous material,or a mixture containing a hazardous material in a quantity equal to or greater than 55 gallons,500 pounds,or 200cubic feet at any one time in the year? I If"Yes;how long have you handled these materials at your business? If"Yes,"check any of the following conditions that applies to your business. I 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. ilk ❑B. This business is a health care facility(doctor, dentist,veterinary,etc.)and uses only medical gases. 17C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an agricultural or horticultural commodity. I Q3. ❑Yes o- Does your business handle an acutely—hazardous material? See definition on reverse side of this form. F 1 Q4. ❑Yes�N6 Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? 1 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. i jOwner or Authorized Agent: X Date:. ij Zr� Name .fir. I Title: Signature I I .. -.�..-. a,.--- rr- .°y`s++i. — '+t`., :: ...Y.'^`.rw.,:+}.tetra..',..4-°�: tiE .-•w..,. _ .T..rw_. r tTxlMfr!..�.� ..+�:. v�..,� - � -�+..e+�. �..•�-...rte._�. .r-w,. 1rw� �fin+.�r's:<-'�r�a.�+�:+.*e�r++.as+.� etc+. ¢. �.rrra�„�:_- i I . I i 1 R