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op41V!M., <br /> Z <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> Telephone(209) 468-3962 # <br /> Hazardous Materials Division(209)468-3969 ; <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this.survey forth. A separate survey for each business name and/or 3' <br /> address in San Joaquin County is required. <br /> Business Name: F t LA KC4 Zf4!j.'A-r-jE3ox-ro <br /> Business Owner(s)Name: JO 04 1%J IEAErA L Telephone: 481-1614 <br /> Business Address: qLZQ ?Nt)RNr'dN )ec/ jrE. 0C rrd w —+A 9SZd9 <br /> Mailing Address(if different from above): } <br /> Nature of Business: VArEA jKt GLvB Fire District: :rA&dVj_guRXV <br /> Q f. )qfes Q 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 form. if your answerls <br /> No,'go to Question 4. <br /> 02. UYes XNo Does your business handle a hazardous material,ora mixture containing a hazardous <br /> material in a quantity equal to orgreater than 55 gallons,500 pounds,or200cubic feet 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 /> II <br /> OA. 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 /> 0B. This business is a health care facility(doctor,dentist, veterinary, etc.)and uses only medical gases. <br /> OC. This business operates a farm forpurposes of cultivating the soil,raising,or harvesting an agricultural or <br /> horticultural commodity, 3 <br /> Q3. UYes 1*O Does your business handle an acute!y hazardous material? See definition on reverse. <br /> side of this form. <br /> Q4. Dyes 'do is your business within 1,000 feet of the outer boundary of a school(grades K-12)? <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety Code. <br /> 1 understand that if l own a facility or property that is used by tenants,that it is my responsibility to notify the tenants of the requirements <br /> which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. 1 declare under the penalty of perjury <br /> that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> X pate: <br /> Pri me <br /> X Title: <br /> Signature <br /> t <br /> 1 <br />