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COUNTY OF SAN J AQUIN <br /> pqulb .c OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue, Suite 3-- <br /> " ` Stockton, California 95202 <br /> Telephone (209) 953-6200 <br /> F a" <br /> Fax (209) 953-6268 <br /> HAZARDOUS MATERIALS 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: _GctVO-1)WA-2A GUrZ (Vftfe- Ie-A-C Pf lKtj TEMPL6 � <br /> Business Owner(s) Name: D}At442PrM 5lN61-f Telephone:(209 321 ---To-4 <br /> Business Address: ( 6 1.1 N L 420{}n ��(LA-rte G� Q x5so!-( <br /> Mailing Address (if different from above): <br /> Nature of Business: SI K 1-t TE M P L t _ Fire District: <br /> Q1.>;ryes ❑No Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material on the back of this form. If your answer is No," go to Question 4. <br /> Q2.)q'es []No Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at any one time in the year? <br /> If"Yes," how long have you handled these materials at your business? 12 y�1S <br /> (--rWo 1°K-uePrNF '(MAKf sq- J <br /> S o <br /> ao P � GAr-. Fa--e- <br /> If kl?ritGN (/Sr> <br /> "Yes,"check any of the following conditions that ap lies to your business. <br /> 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 /> ❑B. This business is a health care facility(doctor, dentist, veterinary, etc.) and uses only medical gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes �No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes)s o Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <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 is 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 under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> X n K fi-t2-p nA S I N G(1 Date: n 4 11z1 I 0 <br /> Print Name J _ <br /> X Title: O1ocI NE 2 <br /> Signature <br /> F:10EVSVMP1anning ApphwUon Forms\Use Permit(Revive 02-03-10) Page 6 of 9 <br />