SU0006069 - Laserfiche WebLink

Home Browse Search

COUNTY OF SAN JOA'--41N OFFICE OF EMERGENCY&eRVICES Room 610, Courthouse 222 East Weber Avenue Stockton, California 95202 Telephone (209) 468.3962. r r`oRsi . Hazardous Materials Division (209)468-3969 HAZARDOUS MATERIALS DISCLOSURE SURVEY I?Cease read ttie triformation on the rev a side before c�plot�ng this survey far ii: A separa#e'survey for each business name andt&address in Sail Joaguiin-County is.r+"fired. Business Name: 51ir7� 1=1 Business ChMner(s)Name: Tele phone: 75 1 ' S7 Business Address:. 100 86 Mailing Address(if different from above): XS A30qr, Nature of Business: Fire District: Q1. ©Yes ■No Does your business handle a hazardous material in any quantity at arty one time in the year? See the definition of hazardous material on the back of this form. If your answer is No,go to Question 4. i Q2. OYes Ohio Does your business handle a hazardous material,or 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? ! - I' � t If"Yes,"check any of the following conditions that applies to your business. OA. The hazardous materials handled by this business is 6ontained solely in a consumer product, packaged for direct distribution to,and use by,the general public. OB. 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. 03_ ©Yes ■No Does your business handle an acutely hazardous nnaterial? See definition on reverse side of this form. Q4. ElYes ®No 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 udder Chapter 6.95 of the California Health and Safety Code. i understand that if I own a facility or property thafis used by tenants,that itis my responsibility to notify the tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of per)ury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owner or Authorized Agent: X -• Date: A /of, X <j� _ _ Title:—� ! _ Signature