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COG <br /> -� SAN JOAQUIN COUNTY <br /> Piartning/BIdg Dept <br /> �.. .� OFFICE OF EMERGENCY SERVICES1=,Ee<,,:Na. <br /> �. � HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> ��.FoRr <br /> PLEASE PRINT OR TYPE <br /> 01. Please provide a separate survey for g= business name and/or address in San Joaquin County: <br /> a. Business Name: Nahama & Weagant Energy Company <br /> b. Business Owner(s) Name: same as above Phone:(805) 323-9075 <br /> C. Facility Address: 22991 S. Chri sman Road, Tracy, CA 95376 <br /> d. Mailing Address: 602 H. Street <br /> Bakersfield, CA 93304 <br /> e. Nature of Business: Oil & Gas Exploration & Production Fire District: Tracy <br /> f. Business Lic. No: Expires (Mo/Yr) Standard Indstrl Code No: <br /> g. Proposed Project: The drilling of a natural gas well <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 (EHS), 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 0 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 [3. No <br /> 05. Will proposed building or modified facility be within 1,000 feet of the outer boundary of a school (grades K-12)' <br /> Yes ❑ No 0 <br /> have read the Hazardous Materials Information Guide (on back page) and understand my require- <br /> ments under Chapter 6.95 of the California Health and Safety Code Sections 25505, 25533, and <br /> 25534. 1 understand that If the building does not currently have a tenant, that It Is my responsl- <br /> blllty to notify the occupant of the requirements which must be met prior to Issuance of a <br /> Certificate of Occupancy. <br /> Owner or Authorized Agent: <br /> (Print) Barry M. Boone, Agent for lahama & Weagant Energy Company This <br /> (Signature) Date 9-17-92 <br /> r <br /> t. San Joaquin Alr Pollution Control District 2. Omes of Emergency Services <br /> 2321 W. Washington 3t, Sults 1 Hazardous Materials Division <br /> Stockton, CA 95203 (209) 461-3470 222 E. Weber Ave., Courthouse-Rm 510 <br /> Stockton, CA 9S202 (209) 463-3969 <br /> OES IHSP _ DATE <br /> APPROVE REJECT _ VERIFIED _ <br /> HUMP — RUPP _ EXEMPT_ V.3.0/92 <br />