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L. 4`0 <br /> VOW <br /> t a� <br /> �Q ,N COUNTY OF SAN JOAQUIN 2 2001 <br /> >a ` OFFICE OF EMERGENCY SERVICES RONALD eI dR1CDt <br /> ?.� ROOM 610.COURTHOUSE DIREC AQdiI.-GWRiY <br /> 222 EAST WEBER AVENUE ENIERG Dffff cyss uE <br /> " STOCKTON,CALIFORNIA 95202 <br /> ctCikop''� 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 reed. <br /> Business Name: <br /> ®�9//XF �ia�o� �i9� ��✓ /1����elephone: ��J7 — ® U�o <br /> Business Owner(s)Name:6411, <br /> 7y <br /> r <br /> Business Address: _3Z <br /> A/ <br /> Mailing Address(if different from above): <br /> OO <br /> A �9- -.f /L,. _- _A Aoo�iS'--�� Fire District: <br /> Nature of Business: o9Q/�Q! �cri/t.etrx <br /> Q 1. ZlYes �]No Does your business handle a hazardous material in any quantity at any one time in the[ear? Seet 4e <br /> �� ��definition of hazardous material on the back of this form. If your answer is"No",g Question <br /> Q2. V,, es No Does your business handle a hazardous material,or a mixture containing a hazardous material,in a <br /> quantity equal to or greater than 55 gallons,500 pounds,or 200 cubic feet at any one time in the year? <br /> If"Yes",how long have you handled these materials at your business? 11 off e I e r c <br /> If "Yes",check any of the following conditions that applies to your business? <br /> Ve A. 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 /> ::=) B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses only medical gases. <br /> C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3, 7]Yes '_t,No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. -Yes 7290 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 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 <br /> the 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 /> KS E'N— Date <br /> Print Name <br /> TiIleererr� ��CSVvO�C'iV <br /> X $tgna[ure - (Rev 4/99) <br />