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COUNTY OF SAN JOAOU/N <br /> ,.����s.., OFFICE OF EMERGENCY SERVICES <br /> 2'10'1 E.Earhart Avenue,Suf[a 3- <br /> Stockton,CaliTomia 96202 <br /> _ Telephone(20H)963-6200 <br /> yyyp Fax(209)BS3-6268 <br /> HAZARDOUS MATERIALS OISClO6URE SURVEY <br /> Please raatl the infohneLlon on the reverse side before completing tMs survey form. A separate survey for each business <br /> name and/or etldrassTin^s`en Joaquin County IB requirotl./� 1 <br /> BV61nHBa Nama: .1 XA'�'n ��-tY-lGt \17 � (i� � 1 ]� <br /> Business Ownar(a)Name: Telephone: a�- :J Jam) "- (�Z°�� <br /> Bgaln¢sa Adtlree6: l0 L���-� i� �P�-F'��XY�(),X� I_.QX1Q�y�f7\ G���"34G` <br /> Mailing Address(H dlHarent from above): <br /> NaNr¢of Businas6: (� CQt�� YX 1(Y l Yl(Y Fire OialrieL F.AOV_P(l:.'M VtIL <br /> 01, m4 a ONo Ooas yOgr basine6s handle a hazardou6 ntatadel In any quantlly Hl Hny Ona lima in the yaaR Bea the <br /> dagnilion of hazartloua material on the Dadr Of this Tomr. Hyour answer is No.'gp to Ouasgon 4. <br /> 02. OYas ��Jo OOes your buainasa handle a hazardous material,or a mixture canlalning a hnzardouc material in e <br /> quantity¢qual to or greeter than 55 gallons.500 pounds,or 200cubic feat at any one Hma in the yea/l <br /> If-Yes;how lonfl have you handled N¢a¢materials Ht your Ducinesa4 <br /> It-Yea,-ch¢ck any of Lha folbwing opntlilrons that applie6 to your Dusinaefi. <br /> OA. The hazardous materials hantll¢d by Ihle Duslnaea is wn[ainetl eololy in a consumer product, <br /> packegatl fpr direct diatdbution to.antl V9b by,the gan¢rel public. <br /> 06. TMa business fa a health rare facility(tlocloq tlangsh veterinary,etc.)antl uaea oniv medical Bassa. <br /> OG TNB Dudnasc operates a farm for purpo6ea of cultivating fha colt,raising,or harvesting an <br /> egrfoukurel or horticullurel commodity. <br /> 03. �Yas f9flo Deas your business handle an acubly hazaMoua matartal4 Sea dagnition on remorse Aida dthis/orm. <br /> 04. OYoa � le your bualnase within t,0D0 faai Of Lha outer bountlary of a school(grades K-12)4 <br /> 1 have reed the infonnalion on this Torm and underslentl my requlremanfs under Chepler 6.86 of the CaOtomla Haslth and <br /> Safety Code. 1 underslentl Ihet H I own a faeliily or prepariy that ifi used by tenants,that it is my recpona{bility to no1Hy the <br /> tenants oT th¢requirements which must ba mat prior to Issuance of a Cartilicata of Owupency or ba9lnning of oparetlona. 1 <br /> datlara under the penalty of perjury Lhal the Infomtetlon previdatl on this tliacloaura survey is Vua end accureta b Ne beat <br /> of my knowlatlfle. <br /> Owner or Authoriz¢tl AganC <br /> x /+� is Data: ?/St/i <br /> x � Tiu.: yYef zY /Y/i4.v�aG�r��GEz 19�t,/<J.�,�s/> <br /> c IDsysvcva.m..a weslc.a..ne.,�..tu..r.....�_<n..,..e ox�ea-+ol Page a o/g <br />