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Office Use Only <br /> Dept.: <br /> SAN JOAQUIN COUNTY Lrile P; _ _ _ _ _ __ <br /> OFFICE OF F•,MERGENCY SERVICES <br /> HAZARDOUS NIA'fERIALS DISCLOSURE SURVEY <br /> ELEASF. PRINT OR TYPE <br /> Q1. Please provide a separate survey for c;,ch business name :rad address in San Joaquin <br /> County: church <br /> a. Business Namc: Stockton Fil/Am Seventh Day Adventist Phone: (vtn) »e-2n-,2 <br /> b. Mailing Address: c/o Ladish Construction Management, Inc. <br /> 575 Lincoln Ave, # 205 Napa, CA 94558 <br /> c. Facility Address: 3250 Guernsey <br /> Stockton, CA 95205 <br /> d. Contact Name: Tex Ladish Phone: (707)224-2062 <br /> e. Nature of Business: Church <br /> f. Proposed Project: New Church <br /> Q2. Will the owner, applicant or future building occupant handle a hazardous material? <br /> (includesasoline, oil, propane, oxygen, acetylene, ammonia, chlorine, pesticides. . . . ) <br /> M Yes [:�] No <br /> Q3. Will the owner, applicant or future building occupant handle an Acutely Hazardous Material? <br /> (List of Acutely Hazardous Materials available nt the Planning Department) <br /> II Yes 0 No <br /> Q4. Will the proposed building or modified facility be within 1,000 feet of the outer boundary of <br /> a school ( ra I s K - 12)? <br /> Yes Fx-1 No <br /> 1 have read (he ila-rardmis Materials Information Guide (on hack page) and understand me <br /> requirements under Chapter 6.95 of the California Health and Safety Code Sections 25505, <br /> 25533, and 25534. 1 understand that if the building floes not currently have a tenant, that it is <br /> my responsibility to notify the occupant of the requirements which must be roe( prior to issu- <br /> ance of a Certificate of Occupancy. <br /> Owner or Authorized Agent: (Print) Tex Lada h a <br /> Date: �� .�� -5 i (Signature) '1 <br /> (Office Use Only) <br /> 1 . Son Joaquin nIr Pollullnn Cnnlrnl nlstrirt <br /> 1601 East Rezelton Street <br /> Slotktnn, ER 95205 <br /> (209)460-3470 <br /> 2. Son Joaquin Counli; nEs <br /> 222 East Illeber Avenue, <br /> Room 610 <br /> Stockton, En 95202 <br /> (209)944-2116 <br /> t .a <br />