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low <br /> i �fJ <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610,Courthouse <br /> 222 East Weber Avenue <br /> Stockton,California 95202 <br /> TelephoneJ209)468-3962 <br /> Hazardous Materials Division(209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the Information on the memo side before completing this survey form. A separate survey for each business <br /> name and/or address In Sen Joaquin County Is required. - <br /> Business Name: " A v. a a' r`N S C <br /> \ sh7 _374`/ <br /> Business Owner(s)Name: �Kms^ - 'v' A /'A GTeleph(o�ne: 5rb�7 <br /> Business Address:�� 3�x � uf e \ A 9sas <br /> Meiling Address of different from above): n(1\ n� <br /> Nature of Business:_\,J/ NC- C A t Fire District:\ A)0019 13 <br /> Q1. Dyes No Does your business handle a hazardous material In any quantity at any one time in the <br /> year? See the definition of hazardous material on the back of this forth. If your answer Is <br /> No;go to Question 4. <br /> 02. DYes ISN., Does your business handle a hazardous material,or a mixture containing a hazardous <br /> material In a quantity equal to or greater than 55 gallons,500 pounds,or 200cublc feel at <br /> any one time in the year? <br /> If-Yes;how long have you handled these materials at your business? <br /> If'Yes;check any of the following conditions that applies to your business. <br /> DA. The hazardous materials handled by this business Is contained solely In a consumer product, <br /> packaged for direct distnbutlon to,and use by,the general public. <br /> DB. This business Is a health care facility(doctor,dentist,veterinary,etc.)and uses only medical gases. <br /> OC. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. DYes MAI Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. DYes BNo Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? <br /> I have read the Informallon 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. 1 <br /> declare under the penally of perjury that the Information provided on this disclosure survey is true and accurate to the best of <br /> my knowledge. <br /> Omer or Authorized Ay\ant: <br /> X J 04.n o,s> A A 9 ti A Date: 0 <br /> Print Neme <br /> X Tltie:�re S <br /> Signature <br />