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COUNTY A JOAQUIN o$ OFFICE OF EMERGENCY SERVICES RONALD E . BALDWIN 2101 E . Earhart Avenue , Suite 300 DIRECTOR OF :, M ' ..� ��a Stockton , California. 95206 EMERGENCY OPERATIONS Telephone (209 ) 953 - 6200 p 04 FAX ( 209 ) 953 - 6268 HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the inforniation 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 : Safari Kid Business Owner( s ) Name : Manoj Vuriti and/or Chandra Sirapu Telephone . ( 510) 585 - 5541 Business Address : 255 W Legacy Drive , Mountain House , CA 95391 Mailing Address ( if different from above) : 800 Henley Court, San Ramon, CA 94583 Nature of Business : Preschool & Childcare Fire District : MHCSD Q1 . ❑ Yes XNo 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 . Q2 . [] 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 ? 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 . ❑ 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 side of this form . Q4 . Yes ❑ No Is your business within 1 , 000 feet of the outer boundary of a school ( grades K42 ) ? I have read the information on this fonn 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 Chandra Sirapu Date : 04/06/2020 Print Name X ----` Title : COO Signature F :\Devsys\Planning Application Forms Page 1 of 2 Hazardous Materials Disclosure Survey ( Revised 03 -09-09 )