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RECEIVED <br /> _ J AUG 4 - 2010 <br /> COUNTY OF SAN JOAQUIN SAN JOAQUIN COUNTY <br /> OFFICE OF EMERGENCY SERVICES OFFICE OF EMERGENCY SERVICES <br /> IrmWjq"�-� Al <br /> 2101 E. Earhart Avenue, Suite 300 <br /> STOCKTTELEPHONE, <br /> CA 95206 <br /> 53-62 <br /> V <br /> TELEPHONE,(209)953 6200 <br /> � FAX: (209)953-6268 <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 and/or <br /> address in San Joaquin County i required. <br /> Business Name: Telephon e: <br /> Business Site Address: <br /> Maili g Addr s(if ifferent/from above): <br /> Busin ame:�lO 1 Qrn phone: v/ -227 -&rZ MZ <br /> Bu ' er A s: 1 <br /> Nature of Business: Fire District: <br /> Q1. ❑Yes *0 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. []Yes o Does your business handle a hazardous material,or a mixture containing a hazardous material, in a <br /> NN 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 conditions that applies to your business? <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 farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. []Yes [-]No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑YesIo 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 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 /> Ownei or Authorized Agent: �/ <br /> X (JW Date L <br /> �7m <br /> Pr' <br /> 1 <br /> X Title ,TI <br /> Signature (Rev 8/08) <br />