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555 <br /> JUL 8 2008 <br /> OFFICE OF BWl�E ERVIC „ <br /> q 7 ORa` <br /> 9�7(0 <br /> COUNTY OF SAN JOAQUIN <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 name <br /> and/or address in San Joaquin County is required. <br /> Business Name: !OC%Ce <br /> Business Owner(s) Name: y/01:0nC Telephone: <br /> Business Address: <br /> Mailing Address (if different from above): M2 &J-S% /�O W ST S'u i IE (/0� <br /> Nature of Business: Fire District: <br /> Q1. 10Yes D No Does your business handle a hazardous material in any quantity at any one time in the year. See the <br /> definition of hazardous material on the back of this form. If your answer is "No,"go to Question 4. <br /> Q2. DYes �No Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br /> equal to or greater than 55 gallons, 500 pounds, or 200c any one time in the year? <br /> If"Yes," how long have you handled these materials at your business? <br /> If"Yes,"check any of the following conditions that apply to your business. <br /> DA. The hazardous materials handled by this business is contained solely in a consumer product, packaged for <br /> 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 agricultural or <br /> horticultural commodity. <br /> Q3. DYes ®No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. DYes l No Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br /> Code. I understand that if I own a facility or property that is used by tenants, that it is my responsibility to notify the tenants of the <br /> requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> X P� � /V D� 'L Date: d S O c <br /> Print Name /� <br /> X -� Title: C-�7ty6o,! e � <br /> Signature <br /> F^BUILDiWG ANCOUTSARCHIVE PRIOR T02MVERMITAPP-COMMERCIAL Ede 0125 do Page 4 of 5 <br /> (R¢v 022&N) <br />