Laserfiche WebLink
anau!n. COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD E.eALDww <br /> r.• fa <br /> e ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 — 40 4 7- <br /> HAZARDOUS MATERIALS SURVEY FORM <br /> Please read the Hazardous Materials Information Guide on the back side before completig is st ye form. A separate form for <br /> each business n or address in San Joaquin County is required: p41¢✓bP`!` Z j 4 <br /> I✓L�, <br /> Business Name. T I y orw� oma, <br /> Business Owner(s) Name: Phone: <br /> Facility Address: l66r) T_ ,,`ia in p 1 0�4,07 <br /> Mailing Address: ) <br /> Nature of Bu 'ness: Fire District: <br /> Ql. Yes D s y r business handle a hazardous material? Read back Daee. If you answered"No"to Question 1, <br /> ✓/ go to Question 4. <br /> Q2. U[ Yes ❑ No Does your business handle a hazardous material or a mixture containing a hazardous material in a <br /> JIJJJ����,,,, quantity equal to or greater than 55 gallons,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 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 operates a health care facility (i.e., doctor, dentist, veterinary...) and uses gnjx medical <br /> 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. ❑ Yes ❑ No This business or building occupant handles an Acutely Hazardous Material?Read back page. <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 Authoriz A ent: <br /> X r n Title <br /> Prim <br /> Date <br /> Signature E <br /> Rev:1 <br />