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1 t <br /> L � <br /> r <br /> A A 9 <br /> COUNTY OF SAN JOAQUIN <br /> c�G OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> :i <br /> m ROOM 610,COURTHOUSE COORDINATOR <br /> •'• = 222 EAST WEBER AVENUE REVE'F V G® <br /> STOCKTON,CALIFORNIA 95202 <br /> TELEPHONE(209)468-3962 JAIr 18 200 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> SANJOAOUINCOUNTY <br /> HAZARDOUS MATERIALS SURVEY FORM OFRCEOFEMERGENCYSERVICES <br /> Please read the info n on the reverse side before completing this survey form. A separate survey for each business name <br /> and/or address in San Joaquin County is required. <br /> Business Name: Morada Self Storage, LLC <br /> Business Owner(s)Name: Morada Self Storage, LLC Telephone: 209-359-8255 <br /> Business Address: 11780 N. Highway 99 Frontage Road, Lodi, CA 95240 <br /> Mailing Address(if different from above): <br /> Nature of Business: Personal Storage Fire District: Waterloo/Morada <br /> Q 1. [ Yes ❑No 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. [XYes 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 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 only 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. L]Yes ®No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes ZINO 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 ertificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information provided on isclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent:: <br /> X -5 �Gvt w Z. G Date <br /> Print Name <br /> X Title <br /> Signature (Rev 10/96) <br />