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U tN C <br /> r :s SAN JOAQUIN COUNTY <br /> OFFICE OF EMERGENCY SERVICES <br /> P...(anntrlg/Bfdg Dept <br /> d;i Foa�'�p HAZARDOUS MATERIALS DISCLOSURE SURVEY File 64.'1` 51`x,r.-M <br /> PLEASE PRINT OR TYPE <br /> Q1. Please provide a separate survey for each business name and/or address in San Joaquin County: <br /> a. Business Name: New West Petroleum <br /> b. Business Owner(s) Name: J. Gilbert Moore Phone: (916) 443-0890 <br /> C. Facility Address: 2705 Country Club Blvd. <br /> Stockton, Ca. 95206 <br /> d. _ Mailing Address: 1831 16th Street <br /> Sacramento Ca. 95814 <br /> e. Nature of Business: Gas Station,Convenience store Fire District: <br /> f. Business Uc. No: Expires.(Mo/Yr) Standard Indstrl Code No: <br /> g. Proposed,Project: <br /> h. If the business is not in operation, when is the approximate date of operation? 7/1/95 <br /> 02. Does your business handle a hazardous material? 'Hazardous Material' means any material that, because of its <br /> quantity, concentration, or physical or chemical characteristics, poses a significant present or potential hazard to human health anc <br /> safety or to the environment if released into the workplace or the environment. (Includes fuels, petroleum products, paints. <br /> propane, oxygen, ammonia (AHM), chlorine (AHM), pesticides, fertilizers, and hazardous 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 hazardous <br /> material in a quantity equal to or greater than 55 gallons. 500 pounds, or 200 cubic feet at any one time? <br /> Yes ® No ❑ <br /> 04. Will the owner, applicant, or future building occupant handle an Acutely Hazardous Material? (List of Acutely Hazardous <br /> Materials available at the Planning Department). <br /> Yes ® No ❑ (Petroleum roducts have one or more components listed <br /> in table E� <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 X❑ <br /> I have read the Hazardous Materials Information Guide (on back page) and understand my requirements under Chapter 6.95 of the <br /> California Health and Safety Code Sections 25505, 25533, and 25534. 1 understand that if the building does not currently have a <br /> tenant, that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a <br /> Certificate of Occupancy. I declare under the penalty of perjury that this disclosure survey is true and accurate to the best of <br /> my knowledge and is made in the City of Stockton California. <br /> Owner or Authorized Agent: <br /> (Print) J. Gilbert Moore Title President <br /> i <br /> (Signature) Date <br /> 1. San Joaquin Valley Unified Air Pollution Control Dist. 2. Office of Emergency Services <br /> North Region Office Hazardous Materials Division <br /> 4230 Kiernan Ave., Suite 130 222 E. Weber Ave., Courthouse-Room 610 <br /> Modesto, CA 95356 (209) 545-7000 Stockton, CA 95202 (209) 468-3969 <br /> 24-Hour Telephone: 1-800-281-7003 <br /> Fax: (209)-545-8652 OES INSP_ DATE <br /> APPROVE REJECT_ VERIFIED _ <br /> HMMP RMPP EXEMPT_ V.5.12t92 <br />