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�LNr Qtr do <br /> o„s tln. COUNTY OF SAN JOAQUIN 50f3 <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> ��c�FORw� STOCKTON, CALIFORNIA 95202 "Ili <br /> TELEPHONE(209)468-3962 "----- <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS SURVEY FORM OCT 2 119% <br /> Please read the information on the reverse side before completing this survey form. A separate sur ey fBFFIFt9SAN ' "114 COUNTY <br /> and/or address in San Joaquin County is required. t /t3PW41f ES <br /> Business Name: 4 VU 1-=C1 IYlr al 2 L P11 �VIG ^�tma�y <br /> Business Owner(s)Name: - I I Telephone:�f(11 ' ��g4f�0 <br /> Business Address: J(7 Inc -rla Cl_ n�(c �j�" <br /> Mailing Address(if different from above): �b�6 <br /> Nature of Business: Fire District: <br /> Q L )Yes ONO 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. 9Yes ONO 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 (hese 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 /> f 113. This business is a health care facility (doctor,dentis(, veterinary,etc.)and uses oily 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. ❑Yes i No Does your business handle an Acutely Hazardous Material'? See definition on reverse side of this form. <br /> Q4. ❑Yes KO Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> I have read the infomtalion 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 tinder 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 rized Agen . �e C <br /> X Date <br /> X <br /> Print Name <br /> -' <br /> Title <br /> Signature (Rev 10/96) <br />