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k <br /> COUNTY OF SAN JOAQUIN <br /> . OFFICE OF EMERGENCY SERVICES <br /> goon 61%.Cop�hWse <br /> east Weber 4vi6m <br /> :Teteptiar (209}; e- 2.: <br /> �Haaa tiQus: sit Divi On.(2?9 .468-395 . <br /> l u airs f1itJC7'tkks bftwsuialw SvRv Y <br /> Please reed the InfarrrgaUM on the re"Irso sida-bo1we.Qornplaift this survey form. A separate survOY for Saab business <br /> rams and/or addrass In San Joaquin CO"is r6quir`W. <br /> t3usiness Name: HOLT OF CALIFORNIA <br /> 209..466.6000 <br /> Business OwnerT8is}Name: KEN MONROE sphomg. <br /> Business Address, 8853 S. MANTHEY ROAD, FRENCH CAMP CA 95231 <br /> MallIngAddress(if different from abflme - PO BOX 8130 STOCKTON, CA 95206 <br /> Nature of Business: EQUIPMENT SALES & SERVICE Fire District: FRENCH CAMP <br /> Q1, Wes ©No Does your business handle a hazardous material In any quantity at any one time in the year? See the <br /> definition of hazardous rnaterlai on the back of this form, if your answer is No,"go to Question 4. <br /> 02, /Dyes ONo Does your business handle a hazardous material,or a mbdure containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons,500 pounds,or 200mbic feet at any one time In the year? <br /> 50 YEARS <br /> It-Yes,"how long have you handfed these materials at your business? <br /> 0"Yes A check any of the following conditions that applies to your business. <br /> E3X 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 /> OB. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses Q&medical gases. <br /> 13C. This business operates a farm for purposes of cultivating the soi4 raising,or harvesting ars <br /> agricultural or horticultural commoddy. <br /> tai• ®Yes ®No Does your business handle an s t? See definition on reverse side of this form. <br /> 04, 12Yes E]No Is your business within 3.000 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 8.85 of the'California Health and <br /> SafeE(Code. i understand that if I own a fadlhty or property that Is used by temants,that It is my responsiblilty.io 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 penury that the Information provided on this disclosure survey is We and accurate to the best <br /> of my knowledge. <br /> Owner or Authorized Agent, <br /> x KEN MONROE Date: I <br /> Prirst a — PRESIDENT <br /> � ,,,� Title: , <br /> Signature <br /> F:14EV5VCWjann"AMUcMjon FonmjStte Appro"J.(ftvised 4.3-00) Page a of$ <br /> I� <br /> d <br />