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Planning/Bldg. Cept. <br /> File No. <br /> �Q�IH COUNTY OF SAN JOAQUIN <br /> r. <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> ' ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> �;. STOCKTON, CALIFORNIA 95202 <br /> � FOg~ <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> �. HAZARDOUS MATERIALS SURVEY FORM <br /> Please read the Hazardous Materials Information Guide on the back side before completing this survey form. A separate form for <br /> each business name and/or address in San Joaquin County is required: <br /> Business Name: Teichert Aggregates <br /> Business Owner(s) Name: Phone: (209) 832-4150 <br /> Facility Address: _ 29099 S. MacArthur Drive Tracy, CA 95376 <br /> Mailing Address: P.O. Box 15002 Sacramento, CA 95851 <br /> Nature of Business: Sand and Gravel Fire District:Tracv Rural Fire <br /> Protection Dist, <br /> r <br /> Q 1. M Yes ❑ No Does your business handle a hazardous material? Read back nage. If you answered"No"to Question % <br /> go to Question 4. <br /> Q2. 13 Yes ❑ 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 200 cubic feet at any one time? <br /> ` If you answered"No" to Question 2,go to Question 4. <br /> If you answered"Yes"to Question 2,do any of the following statements apply to your business?Read <br /> back page. <br /> _1 A. The hazardous materials handled by this business is contained solely in a consumer product packaged for <br /> direct distribution to,and use by,the general public. <br /> J B. This business operates a health care facility (i.e., doctor, dentist, veterinary...) and uses only medical <br /> gases. <br /> J C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural nr POrnCultural zommodity. <br /> 1 <br /> Q3. J Yes No This business or building occupant handles an Acutely Hazardous Material?Read back pie. <br /> Q4. l Yes 9No This facility or modified facility will be within 1,000 feet of the outer boundary of a school (grades <br /> K-12). <br /> �. I have read the Hazardous Materials Information Guide and understand my requirements under Chapter 6.95 of the California Health <br /> and Safety Code. I understand that if the building does not currently have a tenant, that it is my responsibility to notify the <br /> occupant of the requirements which must be met prior to issuance of a Certvlcatc of Occupancy. I declare under the penaln• of <br /> pegury that rhi, disciesure survey/exemption is nue and accurate to the beat of my knowledge. <br /> Owner or Authorized Agent: <br /> Kim Tarbell <br /> Y Title Project Manager <br /> Pnnl c <br /> X —_- Qr,.0 TCY. 16_4ZX _Date T e 4119 el <br /> Sienatare <br />