Laserfiche WebLink
3 <br /> COUNTY OF SAN JC' 2UIN <br /> OFFICE OF EMERGENCYSERVICES <br /> Room 61.0, Courthouse <br /> 222.East Weber Avenue <br /> • Stockton, California 95202 <br /> Telephone (209)-468-3962 <br /> Hazard ous.:Materiais Division .(209)468-3969 . <br /> HAZARDOUS MATERIALS DISCLOSURE`SURVEY <br /> Please read the information oh.the reverse side.before completing-this survey form; A separate survey for each busiriess <br /> name and/or address in San Joaquin County is required. <br /> Business Name: <br /> A q _ <br /> Business Owner(s)Name: tWk- 3 O ^,-tN X PX Telephone: / 71_8'—.02Z <br /> Business Address: eg Aiat-[ CW' _.rrccA-7o A- c4 YSZ-&,S <br /> Mailing Address (if different from.above): .60K .,SAI /rlltt!�­ AV S _ G¢ �'S -`ar 7 <br /> Nature of Business: I sex-r 1S/y .. nlLaGai�_ &4 !y Fire District: 1"AVTCQX11W <br /> Q1. ©Yes No Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material on the back of this form._If your answer is No," go to Question 4. <br /> i KNo <br /> Q2. ❑Yes 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 200cubic feet at any one time in the year? <br /> If"Yes,"how long have you handled these materials at your business? <br /> E If"Yes,"check any of the following conditions that applies to your business. <br /> -❑A. 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. N <br /> i _❑B. This business is a health care facility(doctor., dentist, veterinary, etc.)and uses 2MI medical gases. <br /> i <br /> ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity: <br /> Q3. ❑Yes)_NNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes XNo 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 <br /> Safety Code. I understand that if I own a facility or property 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. <br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best <br /> �. of my knowledge. <br /> Owner or Authorized Agent: <br /> X AI &t, t�_ Date: LOS <br /> P nt Na <br /> ` X r Title: Q Gt.,G21 <br /> t <br /> F:IDEVSV0Planning Application Forms\Site Approval.(Revised 1-3-93) Page 6 of 9 <br />