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W. 1 . Wwjl I I Manning/bldg: Dept. <br /> ,/ OFFICE OF EMERGENCY SERVICES Flle:'.No. <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> P AS PRINT OR TYPE <br /> 01. Please provide a separate survey for 1ACh business name an or address in San Joaquin County: <br /> a. Business Name: _ ,✓ O0 — e— /�� Y/--)/F'-G/i!,--\ <br /> b. Business Owner(s) Name: %c2//-� /1-7C o ✓e Phone:l..?c'%l G!,' <br /> C. Facility Address: fc <br /> i <br /> d. Mailing Address: �./-5 <br /> ,yj�,n,'//v .4 5 -3 <br /> a. Nature of Business: /e� ✓rs Fire District: ti <br /> I. Business LID. No: u/ S-/ Expires�/(Mo/Yr) h Standard Indstrf Code No: / 7 1 <br /> g. Proposed Project: -5-'7 <- --/ /, -1" <br /> 02. Does your business handle a hazardous materia? "Hazardous Material" means any material that, because <br /> of its quantity, concentration, or physical or chemical characteristics, poses a significant present or potential hazard <br /> to human health and safety or to the environment if released into the workplace or the environment. (Includes fuels, <br /> petroleum products, paints, propane, oxygen, ammonia (EHS), chlorine (EHS), pesticides, fertilizers, and hazardous <br /> wastes...). <br /> Yes ZX No ❑ <br /> 03. 1f you answered 'YES' to Question 2 above: Do you handle a hazardous material or a mixture containing a <br /> hazardous material Ina ntity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time? <br /> Yes No ❑ <br /> 04. Will the owner, applicant, or future building occupant handle an Acutely Hazardous Material? (List of Acutely <br /> Hazardous Materials available at the Playning Department). <br /> Yes ElNoL—,1/ <br /> 05. Will proposed building or modifi facility be within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> Yes E] No <br /> 1 have read the Hazardous Materials information Guide (on back page) and understand my requirements under Chapter <br /> 6.95 of the California Health and Salary Code Sections 25505, 25533, and 25534. 1 understand that it the building does <br /> not currently have a tenant that it is my responsibility to notify the occupant of the requirements which must be met <br /> prior to issuance of a Certificate of Occupancy. I declare under the penalty of perjury that this disclosure survey is <br /> true and accurate to the best of my knowledge and is made in the City of _lin California. <br /> i <br /> Owner or A tlhorized Agent: <br /> (Print) h �'l�/H / l't'1✓�- Tst• <br /> ISlgnalure) �'� <br /> Dal* <br /> I. San Jo sti vi Air Pollution Control Dlstrlct 2. office of Emergency services <br /> 2321 vc Washington 3t., 39110 1 Hazardous Materials Division <br /> Stockton, CA 93203 (209) 46x•3470 222 E. Weber AVJ" Courthouse-Rrb 610 <br /> Stockton, CA 93202 (209) 468-3969 <br /> DES INSP DATE <br /> APPROVE REJECT _ VERIFIED _ <br /> HMMP RMPP EXEMPT V.S.0/92 <br />