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05-04-2006 12:39pn Fro-Prometheus Energy r206UT0801 T-402 P.003 F-886 <br /> h , RECEIVED <br /> MAY -4 2W6 <br /> COUNTY OF SAN JOAQUIN <br /> JAN EMUFlUIN UUUN 1Y <br /> �. <br /> OFFICE OF EMERGENCY SERVICES RONALu�lMwypvg�ER6ENCY SE3IVICEs <br /> ROOM 610.COURTHOUSE omactaa DP <br /> 222 EAST WEBER AVENUE EMEROENCY OPERATIONS <br /> • / a�,.� STOCKTON,CALIFORNIA 95202 <br /> 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 name <br /> and/or address in San Joaquin County is required.T <br /> Business Name: Peom r7nh/-'�UWI (7t v'✓Q t� CG//LI P),-yy z —Telephone: /Z04-0,21 7-6e'r2 <br /> us <br /> Bh ssitc Address: �-t .7/ �'L/.�� ,y./ay(,C10!Ilit <br /> Mailing Address(if different from above):.. <br /> Business Owner(s)Name: /Y 9- fLl C ��{`�f� �C/g !,,jTe1ephmr,: <br /> Business Owner Address: 54 6 l f / t <br /> Nature of Business: f r!A S/AJ f- /S VW! jg -r` / P7 vl�_Fin:District: ..5iGe <br /> Ql. DYES ®No Does your business handle a hazardous material in any quantity at any one tune in the year? See the <br /> definition of hazardous material.on.the back o£.this.form..If-your answers"No",go to Questiou4. <br /> Q2. QYes %No Does your business handle a hazardous material,or a mixture containing a hazardous material,in a <br /> quantity equal to or gmater than 55 gallons,500 pounds,or 200 cubic feet at any one time in the year? <br /> If"Yes",how-long-have you handled these matetials at this site? <br /> If "Yes",check any of the following conditions that applies to you business? <br /> E]A. The hazardous materials handled by this business is contained solely in a consumer product packaged for <br /> direct distribution to,and use by,the general public. <br /> -- -- ----[]B, -This hushreea operates a-farm for purpr>,ses of cultivating-the_soil,raising,or barvesting.rn- .. <br /> agricultural or horticultural commodity. <br /> Q3, OYes C�No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this-farm, <br /> Q4. QYrs Wo Is your business within 1,000 feet of the outer boundary,of a school(grades)(-12)? <br /> I have read the information on this form and understand my requirements under Chapter 695 of the California Health and Safety <br /> Code. I undcrstaud that if I own a facility or property that is used by tenants,that it is my responsibility to notify the a tants of <br /> the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and=orate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> R c) 60r/ G[ulA ( Ir— ate s— 1, O 4 <br /> Print Name _/ <br /> x - Title V' t elle-sf fn �... <br /> Signature (Rev 3105) <br />