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AUG. 1.2003 7:28AM DANA CORP STKN 4 NG.849 P. 1 <br /> RECEIVED _ <br /> AUG - 1 2003 <br /> lattnwnwruvcUui91Y Jlt��� 20tl511, <br /> .pp EM G_: lCYSEIIVlCE P�y <br /> COUNTY OF SAN JOAQUIN Ao t FY E <br /> * � OFFICE OF EMERGENCY SERVICES "' s <br /> ROOM 61 WEBER <br /> COf,1RDIN PEOEI ED <br /> 222 EAST R AVENUE <br /> ...�.t STOCKTON, CALIFORNIA 95202 <br /> Y <br /> 71MONE(209)469-3962 rf,fyr <br /> HAZARDOUS MATERIALS DIVISION(209)A611-390) H <br /> -3969 VU 12003 <br /> HAZARDOUS MATERIALS SURVEY FORM '""V !Ilvwm <br /> -,ERGENGr SERVICE <br /> Please read the inlhrmetion on dig reverse side before completing Osis survey form A separate survey I'ur each business name <br /> and/or address in Sm JJ}oarqu`in,Cnunty is regjuirreed/.�� A <br /> Business Namc: <br /> Business Owners)Name: NTAtG�f �I�� 1T•tlt,-1�� Telephone: <br /> Business Address: J S:N <br /> Mailing Address(If different <br /> from above): <br /> Naturt of Dusiness: .0 Fire District <br /> 01. Xes rINo Dues your business handle a hazardous matorisi in any quantity at any one time in the year? See the <br /> definition of hazardous material on the back of this form. Sf your answer is"No", go to Question 4, <br /> Q2 X'cs ❑No Does your business handle a hazardous material,or If miaturc containing a hazardOVS material,to 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? . <br /> If "Yes",check any of the following eoeditiuns that applies to your business'? <br /> 1`1 A. The hazardous materials handled by this husiness is contained solely in a consumer product packaged for <br /> direct dlstrihution in,and use by,the general public. <br /> C3 B This business is a health care facility(doctor,dentist,verorinary,etc.)and uses Qnly.medical gases. <br /> D C. Thi%business operates a faint fur purposes of cultivating the soil,raising,or harvesting an <br /> - - agricultural or horticultural commodity. <br /> Q3. XYes ONo Docs your business handle an Acutely Hazardous Material? See definition on reverse aide of this form. <br /> Q4. ❑ycs *0 is your business within 1,000 feet of the outer boundary of It school(grades K-12)? <br /> f have read the Information on this forth and understand my requirements under Chapter 6,95 of the California Health and Safety <br /> Code. I understand that If 1 own a facility or property that is used by tenants, that it is my respnnsibihly to notify the tenants of <br /> Loc rcquircmcnis which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under(he <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 ate _ <br /> Print Name <br /> K Title <br /> Signature rRsv 10196) <br /> ei ' d E6BH L£6 6oz -+as;uvs0 3Fw.Aad SOO deb= EO 56-02-daS <br />