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• i p4tI.I N_ C . <br /> SAN JOAOUIN COUNTY <br /> OFFICE OF EMERGENCY SERVICES <br /> Planning7Bidg -- <br /> cII� .e• HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> all • �*LIFO P�` <br /> OFfIC JOA IJIN COUNTY I i <br /> apt, Please provide a separate survey for each business name and/or address in San Joaquin County: <br /> a. Business Name: f'C / 1 ,- <br /> __ <br /> tt lfl \/ILEA SJR <br /> b, Business owner(s) Name: ry n L Phone:` <br /> C. Facility Address: U <br /> If <br /> d. Mailing Address: <br /> I �a III t<ena r <br /> Fire District: •�( - - <br /> e. NatureBusiness: / Standard Incistil Code No: <br /> {. Businesss Lic. No: ___---- Expires (MolYr) <br /> g, Proposed Project: <br /> , when is the approximate date of operation? <br /> h- If the business is not in ooeration �-- <br /> 02. Does your business handle a hazardous materiaR 'Hazardous Material" means any material that, because of its <br /> ristics, poses a significant present or potential hazard to human heath anc <br /> quantity. concentration, or physical or chemical characte <br /> safety or to the environment if released into the workplace or the <br /> er and hazardous(includesfuels, petroleum)•p products, paints. <br /> propane, oxygen, ammonia (AHM), chlorine (AHM), pesticides, fertilizers, <br /> Yes ® No 0 q <br /> Q3. If you answered'YES'to Question 2 above: Do you handle a hazardous material or a mixture containing a hazardous <br /> material in a quantity equal to or greaterthan 55 gallons, 500 pounds. or 200 cubic feet at any one time? <br /> Yes El No <br /> Q4, Will the owner, applicant, or future building occupant handle an Acutely Hazardous Material? (List of Acutely Hazardous <br /> Materials available al the Planning Department). <br /> Yes ❑ No MV <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 10 <br /> 1 have read the Hazardous materials information Guide (on back page) and understand my requirements under Chapter 6.95 0! me <br /> I have <br /> Health and dour Coda s inform tion 25533, and 25534. 1 understand that 11 the building does not currently have a <br /> Tenant, flat l is my Safety <br /> Code sections <br /> ty ti no 25tify 5. occupant o! the requirements which most be met Prior to Issuance of a <br /> Certificate <br /> o/ Occupancy. I declare under the penalty of perjury that this disclosure S <br /> urvey is true and accurate to the best of <br /> � ,� K.�yt yL California. <br /> my knowledge and is made in the City of <br /> Owner or Authorized Agent: ide <br /> (Pent) <br /> ..✓ <br /> it <br /> Dat(Signature) Faneryency Sarvicea1. San Joaquin Valley Unlned Air Pollution Control Disl. s Materials DNision <br /> North Region office eber Ave.. Courthouse-Roam 610 <br /> 4230 Kiernan Ave., Suite 130 CA 95202 (209) 468-3969 <br /> Modesto, CA 95356 (209) $45-7000 '}24-Hour Telephone: 1.800.281-7003 1C— DATEFax; (209)-545-6652 REJECT _ VERIFIED <br /> RMPP _ EXEMPT <br /> V.5.12192 <br />