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RECEIVED JAN - 92009 SAN JOAQUIN COUNTY COUNTY OF SAN OAQUIN 0FHCE OF EMERGENCY SERVICES r. OFFICE OF EMERGENCY SERVICES RONALD E.BALDW)N :4 ROOM 610,COURTHOUSE COORDINATor{ 222 EAST WEBER AVENUE STOCKTON, CALIFORNIA 95202 Ci o TELEPHONE(209)468-3962 HAZARDOUS MATERIALS DIVISION (209)466-3969 HAZAIZDOUS MATERIALS DISCLOSURE SURVEY Please read the information on the reverse side before completing this survey form. A scparate survey for each business name and/or address in San Joaquin County is 'eqUil-Cd. Business Name: Business Owner(s)Name: Telephone- (!(p Business Business Address: 4W 1 1 tjvrk�VA Mailing Address (if different from above): R:x 171( S V -97Mq Nature of 3�Business: Fire Dish-jct7 6 Ql, V(yes 0No 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, /-Yes ON,o Does you.r 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 200 cubic feet at 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 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. C, Cl 13. This business is a health care facility (doctor, dentist, veterinary,etc,)and uses onlv medical gases, C. This business oprTates,a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or horticultural commodity. Q3. /JY es ON o Does YOUT business handle an Acutely Hazardous Material? See definition OD reverse side of this form. Q4. DYes. 0 Is your business within 1,000 feet.of the outer boundary of a school (grades K-12)? I have read the information OD 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 TCSP01ISi hility to notify the tenants of the requirements which must be met prior to issuance of a Certificate ol'Occupancy or beginning of-ope-rations. 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 Date X PC �1/�-Title llvw VSi kazure (Rev 49(')