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PQM to COUNTY OF SAN JOAQUIN OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN Room 610, Courthouse DIRECTOR OF 222 East Weber Avenue EMERGENCY OPERATIONS Stockton, California 95202 Telephone(209) 468-3962 Hazardous Materials Division (209) 468-3969 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. 1 Business Name: U�5� _r� (,M L44, , YA16 - T Business Owner(s)Name: p U IAL4 Telephone: LJ18 4T)J5 Business Address: /0-0 &x–&'0 6 CIA"- - Mailing Address(if different from above): T Nature of Business: Q/47 Fire District: Q1. C,l�Yes Wo Does your business handle a hazardous material in any quantity at any one time in the year? See the definition L of hazardous material on the back of this form. If your answer is No,"go to Question 4. Q2. dYes ❑No 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?_ ��/� 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 commodityOgyA faL p',eL ?2;vz– Q3. ❑Yes IgNo Does your business handle an acutely hazardous matt'errial? See definition on reverse side of this form. Q4. ❑Yes QNo 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 is 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 perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owner or Authorized Agent: X y / IDate:— PriV Name X /liOLJ /'� Title: Signature F:\Devsys\Planning Application Forms Page 1 of 2 Hazardous Materials Disclosure Survey(Revised 8-25-03)