Laserfiche WebLink
COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> y : Room 610, Courthouse <br /> " 222 East Weber Avenue <br /> Stockton, California 95202 <br /> 9��FORN` 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: nQ _ ��CS q <br /> Business Owner(s) Name: Telephone: to <br /> Business Address: -2 �s L (—(- <br /> Mailing <br /> —C V t n�S�N�C <br /> Mailing Address(if different from above): \ r <br /> Nature of Business: 1��� �\LS� ��\� t�p(�Q bV 1 ( Fire District: <br /> Q1. tes DNo 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 /> Q2. DYesDoes 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 /> If"Yes," check any of the following conditions that applies to your business. <br /> DA. 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 /> DB. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. <br /> DC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> \ agricultural or horticultural commodity. <br /> Q3. ❑Yes �pdo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes l o Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <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 /> Owner or Authorized Agent: I <br /> X 1��� ��C Date: <br /> � <br /> e <br /> X Title: <br /> n�[ure <br /> FMEVEiMPlanning Application Forms\.Site Approval.(Revised 6-03-04) Page 6 of 9 <br />