Laserfiche WebLink
COUNTY OF SAN JO IN <br /> oP " OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue, Suite 3-- <br /> `� Stockton, California 95202 <br /> Telephone (209) 953-6200 <br /> ac;19F40Fax (209) 953-6268 <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: Forward Landfill, Inc. <br /> Business Owner(s) Name: Forward Inc. Telephone: (800) 204-4242 <br /> Business Address: 9999 S. Austin Road, Manteca, CA 95336 <br /> Mailing Address (if different from above): <br /> Nature of Business: Landfill Fire District: Lathrop-Manteca <br /> Q1. xYes ❑No Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material on the back of this form. If your answer is No," go to Question 4. <br /> Q2. xYes ❑No Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at 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 /> ❑A. 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 /> CC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes x No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes x No 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 <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> X Mike Caprio Dater <br /> A/ <br /> -print NarTrp ' <br /> X �r0-� Title: <br /> Signature <br /> F:\DEVSVC\Planning Application Forms\Use Permit.(Revised 02-03-10) Page 8 of 9 <br />