SU0004300 - Laserfiche WebLink

Home Browse Search

°�vada�'t COUNTY OF SAN JOAQUIN OFFICE OF EMERGENCY SERVICES Room 610, Courthouse 222 East•Weber Avenue Stockton, California 95202 Telephonej209) 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. J , Business Name: -.7� �' A 4 Telephone; Business Owner(s) Name: / Business Address:fJ�� -/ / z ��!' -''/ 1 s Mailing Address (if different from above): Nature of Business: Fire District: Q1. '"Yes ❑ No 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. •'( Yes ❑ 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? 1�y,7--r`fi �� If"Yes,"check any of the following conditions that applies to your business. 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. yf ❑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 commodity. Q3. Yes ❑No Does your business handle an acutely hazardous material? See definition on reverse s \ side of this form. 04. ❑Yes )(No 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. f OAvnet,e�Authorized ht• X' Date: X ��L'2°� �!✓' /`�J9 ( %�' Title: �G Signature