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'oPQu IN. , . � OA C`q 4: 0 F o R��P COUNTY OF SAN JOAQUIN OFFICE OF EMERGENCY SERVICES 2101 E . Earhart Avenue , Suite 300 Stockton , California 95206 Telephone (209 ) 953 -6200 FAX ( 209 ) 953-6268 HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the information 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 : � Se celprp; V4 A P--7 ? ��ll � Business Owner(s ) Name : A"PIff3 �� V he ye ;ef Z Telephone : G� Ls^� ^0Z 5 Z Business Address : 9�G �// i i S7cc , /4 > 09 ffh Mailing Address ( if different from above ) : ? Sri; -f� �+ f �.' '�/44;0 " VcyAA WYE e 67Y Nature of Business : v �� i-trc %S '�•�+ Fire District : Q1 . Wes ❑ No 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 . XYes ❑ 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 200c 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 apply 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 ;INo Does your business handle an acutely hazardous material ? See definition on reverse side of this form . Q4 . [] Yes JJNo Is your business within 1 , 000 feet of the outer boundary of a school (grades K- 12 ) ? I have read the information on this form 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 C' n � � G . c1 � r �- Date : Pri t Name X Title : �p s 0470 Signature F :\BUILDING\ HANDOUTS\Check List Commercial Building Permit. doc (Revise01 - 11 - 10) 3 of 4