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COUNTY OF SAN JOAQUIN OFFICE OF EMERGENCY SERVICES ? 2101 E. Earhart Avenue, Suite 3-- Stockton, California 95202 • ' Telephone (209) 953-6200 Fax(209) 953-6268 HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the information on the reverse side before completing this survey form. A separate survey for each business name and/or address in San Joaquin County is required. Business Name: TRACI ULTIMATE- Ppr1NT9fl-L1— INC_ Business Owner(s) Name: As*"1 N C H Pel STOP E R PNTO Telephone: 6cq) g3 05 Business Address: Z pl;-L.s 9 V K cl,s TRP1G�f Ch c C Mailing Address(if different from above): E Nature of Business: NTE�TAIN Mt NT RE -RE'AtloN Fire District:. TRACY I�1.. V� Q1. ❑Yes PNo Does your business handle a hazardous material in an quantity � y q y at any one time in the year. Seethe definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. Q2. ❑Yes ®'No Does your business handle a hazardous material r o a mixture containing a hazardous material in a quantity equal to or greater than 55 gallons, 500 pounds,or 200cubic feet at any one time in the year? If"Yes,"how long have you handled these materials at your business?------ If usiness? -----If"Yes,"check any of the following conditions that applies to your business. ❑A. The hazardous materials handled by this business is contained solely in a consumer product, packaged for direct distribution to, and use by, the general public. ❑B. This business is a health care facility(doctor,dentist,veterinary, etc.)and uses only medical gases. ❑C. This business operates a farm for purposes of cultivating the soil,raising, or harvesting an agricultural or horticultural commodity. Q3. ❑Yes 112�o Does your business handle an acutely hazardous material? See definition on reverse side of this form. Q4. ❑Yes MNo Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety Code. I understand that if I own a facility or property that is used by_tenants._that_it-ls_my-[esponsibility.to_notify.,the- ---enanis of the�equiremerits-which must-be-met-pria-rto-issuance of a Certificate of Occupancy or eginning of operations. I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owner or Authorized Agent:` XPrin---- Date:— - — = I X— `2t7I 1 __----- ------------ --- Nam _-------- Title: W11G'Y —Fya tAt mr tr Paint J Sig e FADEVSMPlanning Application Formsk&ia Approval.(Revised 02-03-10) Page 6 of 9