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J u!N-� <br /> 1 I Z SAN JOAQUIN COUNTY <br /> " Plan ninglBtdg: Dept <br /> &TICE OF EMERGENCY SERVICES Fite.': Na, <br /> c. P HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> gCiF$e� <br /> PLEASE PRINT OR TYPE <br /> 01. Please provide a separate survey )r sack business name and/or address in San Joaquin County: <br /> a. Business Name: T6 It �/ c �t� q C�/v/OAl� <br /> v <br /> b. Business Owner(s) Name: Phone: 5`7'7 --7600 <br /> C. Facility Address: /)sS /N. <br /> d. Mailing Address: PO .SOX <br /> A 0 s <br /> e. Nature of Business: /�c��_rC-GF;, /meq/ 4f=,0g,1„�_ Fire District: oZ <br /> f. Business Lic. No: 2 Expires (Mo/Yr) !,� 2 Standard indstrl Code No: S� <br /> g. Proposed Project: fRrni< jprq� lfd,41t <br /> 02. Does your business handle a hazardous material? "Hazardous Material" means any material that, because <br /> of its quantity, concentration, or physical or chemical characteristics, poses a significant present or potential hazard <br /> to human health and safety or to the environment if released into the workplace or the environment. (Includes fuels, <br /> petroleum products, paints, propane, oxygen, ammonia (EHS), chlorine (EHS), pesticides, fertilizers, and hazardous <br /> 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 <br /> hazardous 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 <br /> Hazardous Materials available at the Planning Department). <br /> Yes ® No ❑ <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 ® , <br /> I have read the Hazardous Materials Information Guide (on back page) and understand my requirements under Chapter <br /> 6.95 of the California Health and Safety Code Sections 25505, 25533, and 25534. 1 understand that if the building does <br /> not currently have a tenant that it is my responsibility to notify the occupant of the requirements which must be met <br /> prior to issuance of a Certificate of Occupancy. I declare under the penalty of perjury that this disclosure survey is <br /> true and accurate to the best of my knowledge and is made in the City of 5 oc /CTc ._, California. <br /> Owner or Authorized Agent: <br /> / / <br /> (Print) �� ///r'��� // G Kai d i <br /> Title L-!r--) 7t 5f& .�. <br /> ;Signature) a <br /> Date <br /> 1. Son Joaquin Air Pollution Control maKet 2. Office of Emergency Services <br /> 2321 / Washington St., Suits 1 Hazardous Materiels Division <br /> Stockt�\CA 95203 (209) 468-3470 222 E. Weber Ave„ Courthouse-Rm 610 <br /> Stockton, CA 95202 (209) 468.3969 <br /> OES INSP _ DATE <br /> APPROVE REJECT _ VERIFIED _ <br /> HMMP_ RMPP_ EXEMPT_ V.5.0/92 <br />