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to <br /> °o\ <br /> SAN JOAQUIN COUNTY P€anningMdg Dept <br /> _ OFFICE OF EMERGENCY SERVICES Ei€e:<:Na: <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> C P <br /> �CrcpR� <br /> Pt EA$E PRINT OR TYPE <br /> 01. Please provide a separate survey for soh business name and/or address in San Joaquin County: <br /> a. Business Name: DEL RIO WEST PALLET <br /> b. Business Owner(s) Name: CANDELARIO V VILLALOBOS Phone: (209) 464-7912 <br /> C. Facility Address: 801 E ROTH RD <br /> FRENCH CAMP CA 95231 <br /> d. Mailing Address: SAME <br /> e. Nature of Business: PALLET SALES Fire District: FRENCH CAMP <br /> f. Business Lic. No: PENDING Expires (Mohr) Standard Indstrl Code No: <br /> g- Proposed Project: PALLET YARD <br /> 02. Does your business handle a hazardous material? "Hazardous Material" means any material that, because <br /> of its quantity, concentration, or physical or chemical characteristics, poses a significant present or potential hazard <br /> to human health and safety or to the environment if released into the workplace or the environment (Includes fuels, <br /> petroleum products, paints, propane, oxygen, ammonia (EHS), chlorine (ENS), pesticides, fertilizers, and hazardous <br /> wastes...). <br /> Yes ❑ No <br /> 03. If you answered "YES' to Question 2 above: Do you handle a hazardous material or a mixture containing a <br /> hazardous material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time? <br /> Yes ❑ No ❑ <br /> 04. Will the owner, applicant, or future building occupant handle an Acutely Hazardous Material? (List of Acutely <br /> Hazardous Materials available at the Planning Department). <br /> Yes ❑ No [I _ <br /> 05. Will proposed building or modified facility be within 1,000 feet of the outer boundary of a school (grades K-1Z <br /> Yes ❑ No Im <br /> I have read the Hazardous MaltnPlsli3 i%aur��utiv^ Gu fcn l,-k t'+ACJP0 Pr''{ inderstand .mid requlre- <br /> ments under Chapter 6.95 o the Callsvrnla Health #nd :''55^5, 35533, and <br /> 25534. 1 understand that If the b.didii^a Biros n, f ri:rra::'ly hcv'- a tanar:t, i s: is my rC:;p,^4i- <br /> blllty to notify the occupant of the rwquirrarnarit1 S°:ti,Ch :m.u,f be mei p:lcr to Issuance of n <br /> Certificate of Occupancy. <br /> Owner or Authorized Agent: <br /> (Print) MICHAEL VAUGHN Title OWNER <br /> (Signature) Dat• Z5 7 <br /> 1. San Joaquin Air Pollution Control District 2. Office of Emergency Services <br /> 2121 W. Washington St., Sults 1 Hazardous Materials Division <br /> Stockton, CA SS203 (209) 464-3470 222 E. Weber Ave., Courthouse-Pim 610 <br /> Stockton, CA 9S202 (209) 469-3969 <br /> OES INSP _ DATE 1_ _ <br /> APPROVE REJECT VERIFIED _ <br /> HMMP — RMPP EXELPT_ V.3.0/92 <br />