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05/16/2006 13:16 F.41 4153464965 KESTERIN EXHIBITORS Q 002/005 GEORG A RODRIGUF� 9460728 0511F 'OG 0H:12pm P. 002 COUNTY OF SAN JOAQUIN e -,� o.�t!v OFFICE OF EMERGENCY SERVICES r. ? Room 610, Courthouse e 222 East Weber Avenue a Stockton. Califomia 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. Business Name: — C p Business Owner(s)Name: �� /> f/7 /JG , Telephone' s Business Address: Mailing Address (if different from above):52d Nature of Business:�� iliYl��ll!^�/!p�/�Fire District_ Q1. OYesXNo Does your business handle a hazardous material in any quantity at any 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- 02. ❑YesXNo Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity equal 10 or greater than 55 gallons, 50D 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_ 08. This business is a health care facility(doctor,dentist, veterinary, etc.)and uses only medical gases_ OC. This business operates a farm for purposes of cultivating the soil,raising, or harvesting an agricuttural or horticultural commodity. 03. ClYesNo Does gear-business handle an scutehr hazardous mat�erfal? -See definition on reverse side of this form. 04. DyesXNo Is your business within 1,000 feet of the outer boundary of a school{grades K-12)? 1 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 WENDY TONKIN _ Date: MAY 16, 2006 Print Marne X Title: SECRETARY B M TONKIN, INC. rgnat (FORMERLY WESTERN EXHIBITORS, INC. ) F-0EVSvCWIamvna Aoplic tion Forms\Sile Approval.(Revised 1-Z-03) Page 6 of 9 _