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a4K4a..E>".per SAN JOAOUIN COUNTY OFFICE OF EMERGENCY SERVICES HAZARDOUS MATERIALS DISCLOSURE SURVEY ...�'il•raw�'�Y. COMMUNITY DEVELOPMENT DEPARTMENT FILE NUMBER: PLEASE PRINT OR TYPE 01. Please provide a separate survey for each business//name anal/`or address In San Joaquin Courtly: Business Name: / Business Owner(s) Name: /1 nn -- ,,JJ'__ �/ �/ / PHIOrNF- ( led 9,577-,V/y0/ Facility Address: 17 �/J C5,907!�/ lyoin7�/)//Gv c�d,^�// O /i//�7 o�'.5,i3O Melling Address: �Q0<�0 C�/�Jr/.C� ��d' Ji�Gr G-� %/50� /- Nature of Business: //Ci7'I.�'"J7/SSJoi'/ �c�OJ`%i�A O� /� D G�O�sin✓�J/CcJ 4 .JJtnaA Fire District: /J/ a"Acl 6c, 2/-124 3 L/2�✓.��/J� +�� Business license No. �.J `UCX �ix.�Vy%NMrea(Mo/Yr) Standard Industrial Code No. Proposed Project: /C�/yl�t✓ l0/YI/Y/✓J?��f/" O/!S 7AGi/f�/ 02. Dose your business handle a hazardous material? 'Hamidous Material-means any material that.because of he quantity,concentraflon, or physical or chemical characteristics,poses a significant present or potential hazard to human heafth and safely or to the environment H released Into the work place or the environment. (Includes fuels, pebobum products, palms, propane, oxygen, ammonia (EHS), chlorine (EHS), pesticides,fertilizers,and hazardous wastes). YES ❑ N0,121- 03. If you answered "YES"to Question 2 above: Do you 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 orts time? Q-S04YES ❑ No-d- 04. . WIII the owner, applicant, or future building occupant handle an Acutely Hazardous Material? (List of Acutely Hazardous Materials available at the Community Development Department). YES ❑ NQe' 05. WIII proposed building or modified facility be within 1,000 fast of the outer boundary of a school (grades K-12)? YES ❑ NO-O' I have read the Hazardous Materials Information Guide (on back page) and understand my requirements under Chapter 6.95 of the California Health and Safety Code Sections 25505, 25533, and 25534. I understand that if the building does not currently have a tenant that it Is my responsibility to notify the occupant of the requirements which must be met prior to Issuance of a Certificate of Occupancy. I declare under the penalty of perjury that this disclosure survey Is true and accurate to the best of my knowledge and Is made In the City of California. .-�iy�`i ��,n�.,�>` o. �. a. J�TT•U.ra�s3 �iir� ✓lt..�� ,�///„..,.ui (PRINT) (OWNER OR AUTHORIZED AGENT) (1717112) /O (SIGNATURE) (DATE) (i] AIR POLLUTION CONTROL DISTRICT (2] OFFICE OF EMERGENCY SERVICES 4230 KIERNAN AVENUE, SUITE 130 HAZARDOUS MATERIALS DIVISION MODESTO, CA 95356 (209)545-70DO 222 EAST WEBER AVENUE, COURTHOUSE RM-510 STOCKTON, CA 95202 (209)46&3969 OES INSP DATE APPROVE REJECT VERIFIED_ HMMP RMPP VERIFIED (1)