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COUNTY OF SAN JOAQUIN OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN ROOM 610,COURTHOUSE DIRECTOR OF 222 EAST WEBER AVENUE EMERGENCY OPERATIONS STOCKTON,CALIFORNIA 95202. TELEPHONE(209)468-3962 HAZARDOUS MATERIALS DIVISION(209)468.3969 HAZARDOUS MATERIALS DISCLOSURE SURVEY 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 AJoaquin County is required. Business Name: 0 Business Owner(s)Name:: t Svz,Ck V-wl-t. ��- �� , Telephone: Business Address: II (� � ,Q nA Mailing Address(if different from above): of u A k 1^✓VN G ki, I� �`_ 14 CQ AMp6 220 Nature of Business: n)/A - - Fire District: Q 1. Yes 0 Does your business handle a hazardous material in any quantity at any one time in the year? See the y definition of hazardous material on the back of this form. If your answer is"No",go to Question 4. Q2. _YeslNo 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 in the year? 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?, ❑ 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 is a health care facility(doctor,dentist,veterinary,etc.)and uses D&medical gases. ❑ C. This business operates a farm for purposes of cultivating the soil,raising, or harvesting an agricultural or horticultural commodity. Q3. ❑Yes Io Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. Q4. ❑Yeso Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? I have read the information on this fora[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: X �LYL Date 2i t Na d Q �Q X Title Signature (Rev 4/99)