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rh ). <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 EasfWeber Avenue <br /> Stockton, California 95202 <br /> TetephoneJ209)468-3962 <br /> Hazardous Materials Division (209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the Information on the reverse aide before completing this survey form, A separate survey for each business <br /> name and/or address in San Joaquin County Is required. <br /> Business Name: G`t-E S Lr (+' L <br /> _ <br /> Business Owner(s)Name: �i9 +•c FC-h�rJ Telephone: <br /> Business Address: 1292 3 7 4 ✓J7/ j E'er C/9 5 <br /> Malting Address(if different from above): r <br /> Nature of Business: L✓1,✓E Fire District: ���✓ — <br /> Q1. Oyes ANo 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 form, If your answer Is <br /> No;go to Question 4. <br /> ous <br /> 02. OYea ❑ No Dos materiel in a quantity equal to our business handle a r greater hana551gallons,1500 pounds,or 200cublcd feet at <br /> any one time In the year? <br /> If'Yea;how long have you handled these materials at your buslness7 <br /> If'Yes;check any of the following conditions that applies to your business. <br /> OA hazardous materials <br /> direct distributionled to and use by,the general this business is isolely In a consumer product, <br /> public. <br /> OB. 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 sail,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. Oyes ❑No Does your business handle an acutely hazardous mntorlal? Soo definition on reverse <br /> side of this form. <br /> 04. OYes '(No Is your business within 1,000 feel of the outer boundary of a school(grades K-12)7 <br /> 1 have read the Information on this form and understand my requirements under Chapter 0.98 of the California Health and <br /> Safety Code. I understand that If I own a facility or properly-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. I <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 /> Owner or Authorized Agent: <br /> x /a v C PF h f3 J Dale: 3 - 1 3 - a 3 <br /> x �. Pd � N% �C � r� d � S <br /> Pa <br /> True: <br /> Signature <br /> 1, <br /> ou qto I <br /> ,y o' IUII• <br /> •• it'to hr,a <br /> Arca n. <br /> i••rl MHlt0 <br /> i y <br /> i <br />