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yK NRY-30-1996 13:12 ]r►_STOCKTON PERMIT CENTER 209+937+ee93 P.01 <br /> ! r71,W. <br /> A <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> y. ROOM 61.0,COURTHOUSE <br /> 222 EASTWEBER AVENUE <br /> a W;�• STOCKTON CALIFORNIA 95202 9P Iwo <br /> TFIPPHONE(209)468-3962 <br /> HAZARDOUS tdATEE}WLS DIVISION(209)468-3%9 a� YNIES <br /> HAZARDOUS MAtERIALS SURVEY FORM <br /> Please read the Hazardous Materials Information Guide on thei back side before completing this survey form. A separate form for <br /> each business name and/or address in San Joaquin County is rerjuired: <br /> Business Name: ouix 6Tce exa.2/CrT 5#Sq <br /> Business Owner(s) Name: QuI'le 67,9P MA12,&A 7/X Phone: (S/o) 65� — 8 So 0 <br /> Facility Address: 0;2 8 5 E, F rt t=_lwt nN'f S I rc��t 5 �c �x� ( 95'.70,S- <br /> Mailing <br /> 5.70,Mailing Address: Poe ownerc— Y.S6-2- EvOr r2 pr2j6e S+ FarhiotiTi (A9 7Y538– �0.5 <br /> Nature of Business: COn0chirLce. 5}vn.L_ .1- 6-aaolin 5ulcs Fire District: fi+Y oFS{ocic+oyl <br /> Ql. ( Yes ❑ No Docs your business handle a hazardous material? Read back page. If you answered"No"to Question 1, <br /> go to Question 4. <br /> Q2- Yes ❑ No Docs your business handle a hazardous material or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 551gallons,500 pounds,or 200 cubic feet at any one time? <br /> If you answered"No"to Question 2,go to Question 4. <br /> If you answered"Yes"to Question 2,do any of the following statements apply to your business?Read <br /> back page. <br /> ❑ A. The hazardous materials handled byj this business is contained solely in a consumer product packaged for <br /> direct distribution to,and use by,the general public. <br /> ❑ B. This business operates a health cart;facility (i.e., doctor, dcntisL veterinary...) and uses only medical <br /> gases. <br /> ❑ C. This business operates a farm f�r purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commoditty. <br /> Q3. ❑ Yes No This business or building occupant handles an Acutely Hazardous Material?Read back ease. <br /> Q4. ❑ Yes No This facility or modified facility will be within 1,000 feet of the outer boundary of a school (grades <br /> K-12). <br /> I have read the Hazardous Materials Information Guide and understand my requirements under Chapter 6.95 of the California Health <br /> and Safety Code. I understand that if the building does not currently have a tenant, that it is my responsibility to notify the <br /> occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. I declare under the penalty of <br /> perjury that this disclosure survey/exemption is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> rtle <br /> Print <br /> att a6 btu,. • 98 <br /> Signature <br /> Rev:l <br />