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RECEIVED <br /> JUN - 2 2011 <br /> COUNTY OF SAN JOAQUccwIN <br /> O <br /> y O NMRGENCYSER CES RONALD E.BALDWIN ( <br /> w ?% ROOM 610,COURTHOUSE COORDINATOR - - E':L,Y SERVIMG <br /> 222 EAST WEBER AVENUE <br /> • Y)tsddNt}• STOCKTON,CALIFORNIA 95202 <br /> _ TELEPHONE(209)466-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS DISCLQSURE 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/J�oaagpuin County is required. 1� /� t7� <br /> Business Name: Ay eppy%, .__& �A(I'�__G,I r.�`1 /� y GuALL Vn(� <br /> Business Owner(s)Name: Yt m /5 wC41 GFWPP,,. Lug p Telephone: (2(A 952-9330 <br /> Business Address: N� W. MAIlU L496 � I> Mt-Tbt4�7 j (A -1S2D7 ��y 'l <br /> Mailing Address(if different from <br /> .above):—b7A2(7 06L T✓te 1>i. S{t Z�J Svtr.�e 1�.'...c�w�e 0#1 �{`!f 13 1 <br /> Nature of Business: I�G71 WRAOT Fire District: U.Y.E V%ew <br /> Ql. , yes DNo 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 ONO Does your business bandle 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? <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 is a health care facility(doctor,dentist,veterinary,etc.)and uses oly medical gases. <br /> 0 C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes JSrjNo Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes NNo 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 orized III: c� r <br /> X <br /> Gt <br /> fr2L �. L'ltiIb� Date <br /> Print Name <br /> R Title <br /> Signature (Rev 10196) <br /> Thursday,October 20, 2005.max <br />