COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

03/23/2010 14:28 2094663336 CAPITAL FEED I-'Att utrnZ i tul~ Ift COUNTY OPSAN JOAQUIN OFFICE OF EMERGENCY SERVICES 2101 E. Emhart Avenue, Suite 300 ' ' •.•� STOCKTON,.CA 95206 `•.p 1� TELEPHONE(209)953-6200 . MAR 2 3 2010 l 3-R-•, ��` _,/ FAX: (209)953-6268 �a SAN JOAq(pN COUNTY JFFICE OF EMERGENCY SERVICES HAZARDOUS MATERIALS DISCLOSU"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. 1 I2 Z Business Name: CfTI t4 L rmo /� Telephone: 416 "f 66 3 •l 3 J Business Site Address: COm 6I e 1 V C. Mailing Address(if different from above): t� Business Owner(s)Name: �+1��fln !) D "S s� Telephone: �r/6 Business Owner Address: C>k r (— 1 -)-/'71 Nature of Business: ` -e.E( F3'- S )/'l�tJ(0 ✓) Fire District Ql. OYesJ0 Does your business handle a hazardous material in any quantity at any one time in the you? See the definition of hazardous material on the back of this form. If your answer is"No",go to Question 4. Q2. OYes *0 Does your business handle a haaudous material,or a mixture containing a hazardous material, in a 77777�� quantity equal to or greater than 55 gallons,500 pounds,or 200 cubic feet at any one time in the year? If"Yes",how long have you handled these materials at your busincss? If "Yes",check any of the following conditions that applies 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 operates a farm for purposes of cultivating the soil,raising,or barvestmg an agricultural or horticultural commodity. Q3. QYes *0 Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form, Q4.. QYes $No 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 renams,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 l �� —IJ--S{'� Date Z3 G Pr X gnature (Rev 8/08)