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• n <br /> rr• ?, . <br /> r <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East•Weber Avenue <br /> Stockton, California 95202 <br /> Telephone,1209)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 <br /> name and/or address in San Joaquin County is required. <br /> Business Name: C�L/ � AJ l �O�W, S <br /> ` ) 763y� <br /> Business Owner(s) Name: ` '© Telephone: <br /> Business Address: <br /> 131 � M I Q� <br /> Mailing Address (if different fro above): `1 c <br /> Nature of Business: <br /> f� 7 Fire District: <br /> Q1. MYes 6No Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the.definition of hazardous material on the back of this form. if your answer Is <br /> No,"go to Question 4. <br /> rial.or a <br /> ous <br /> Q2. 0YO3 o Does <br /> materl In a quantity equal to or greater an 551mixture containing <br /> gallons, 500 pounds,or200cubic <br /> i h <br /> feet at <br /> any one time In the year? <br /> If"Yes,"how long have you handled these materials at your business? _ <br /> If`Yes,"check any of the following conditions that applies to your business. <br /> XA. The hazardous materials handled by this business is contained solely in a consumer product, <br /> packaged for direct distribution to, and use by,the general public. <br /> ❑B. This business is a health care facility(doctor,dentist,veterinary,etc.) and uses only medical gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yeslo Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. OYes ONo Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> I have read the Information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> 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 <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I <br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of <br /> my knowledge. <br /> Owner or Authorized Agent: <br /> X e— Date: <br /> Print,N ip <br /> X Title: <br /> Sigfiature <br />