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RECEIVED <br /> p...gy.:n. FEB 15 2002 <br /> n Zi 8"j0AU0iNCUUN7y <br /> � . <br /> COUNTY OF SAN JOAQUIN +�FFICEOFEMERGENCVSERVYCES <br /> t1AoA�'� <br /> ' <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> Telephone (209) 468-3962 <br /> Hazardous Materials Division (209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the Information on the reverse side before completing this survey form. A separate survey for each business <br /> name and/or address in San Joaquin County Is required. <br /> Business Name:—V is C- C,Ny V,&O4 S<- v C <br /> Business Owner(s) Name:_pF2 gy Imo T SnC-C-0J Telephone: 7P-)- 3Sg-RS`s 1 <br /> Business Address: i7e\fsCe) C-A °t5'z4L <br /> Mailing Address(If different from above): <br /> Nature of Business: Vka" • Fire District: <br /> 01. *as O No Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on the back of this form. If your answer is <br /> No;go to Ouestlon 4. - <br /> 02. MYes O No Does your business handle a hazardous material, or a mixture containing a hazardous <br /> material In a quantity equal to or greater than 55 gallons, 500 pounds,or 200cubic feet at <br /> any one time In the year? l <br /> If'Yes."how long have you handled these materials at your business? myo ltqy, <br /> If`Yes;check any of the following conditions that applies to your business. <br /> OA. The hazardous materials handled by this business Is contained solely In a consumer product, <br /> packaged for direct distribution to,and use by, the general public. <br /> OB. This business Is a health care facility(doctor,dentist,veterinary, etc.) and uses only medical gases. <br /> OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. OYes t1No Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> 04. OYes 1ANo Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> I have read the Information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code. I understand that If 1 own a facility or property that Is used by tenants,that It Is my responsibility to notify the <br /> tenants of the requirements which must be met prior to Issuance of a Certi(Icate of Occupancy or beginning of operations. I <br /> declare under the penalty of perjury that the Information provided on this disclosure survey Is true and accurate to the best of <br /> my knowledge, <br /> Owner a ul o ' e gen <br /> x FRz toTsr a-bate: <br /> Prit ame <br /> X `, Title: [k�µ-- <br /> Ignature <br />