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0 C) <br /> a.autr �. COUNTY OF SAN JOAQt1TN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> r FORS P 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 form. A separate survey for each business <br /> name and/or address in San Joaquin County is required- <br /> Business Name: Wi b r Ellis Co. <br /> Business Owners)Name: Wilbur Ellis Co. <br /> Telephone: (209) 982_5400 <br /> Business Address: .13771S. Prescott Rd Manteca, <br /> Mailing Address (if different from above): <br /> Nature of Business: Agricultural, chemicals & fertilizers. Fire District: <br /> QD <br /> Q1. IaYes ❑No Does your business handle a hazardous material in anany L thr <br /> time in the year? Se <br /> definition of hazardous material on the back of this form. If your answer is No,'go to Question 4.e the <br /> Q2. 13Yes LINO 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? 1989 <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> 0A- 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 only medical gases. <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--LINO-Does your-business handle an acutehazar�r u�mat 'al? See definition on reverse side of this —--- - <br /> Q4. [Was_ form. <br /> QNA--Is yourbusmesswithtn1;000 ee o eQulerbo„�,�r --.-------..---_--.--_ --_---- <br /> ---- - - —-- --- - -- --n-�f-a-sc-hesF(grades <br /> I 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. I <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 /> Note - Facility is currently registered with San Joaquin Co. OES. <br /> Owner or Authorized Agent- <br /> Print Name <br /> Date: 2 I - v- <br /> x _ <br /> Signature Title:,�Y� � As- <br /> FIDEVSVC%PIaming Appiicafion FonnslUse Permit.(Revized"3-o4) Page 6 O <br /> 9 f9 <br />