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U P aPa�t COUNTY OF SAN JOAQUIN a OFFICE OF EMERGENCY SERVICES RonnLn E snLowtn ROOM 610,COURTHOUSE Co,j{wty 222 EAST WEBER AVENUEUl� / I� STOCKTON,CALIFORNIA 95202 TELEPHONE(209)468-3962ICE CF FA7 PGHAZARDOUS MATERIALS DIVISION(209)468-3969 _ IO ._ 1174 V10ES HAZARDOUS MATERIALS SURVEY FORM Please read the information on the reverse side before completing this survey form. A separate survey for each business name and/or address in San Joaquin County is required. Business Name: JAHANT FOOD N' FUEL STOP Business Owner(s)Name: BACHITAR SINGH Telephone: (209) 333-2972 Business Address: 24323 N. HIGHWAY 99 , ACAMPO, CA 95270 Mailing Address(if different from above): SAME Nature of Business: EXISTING RESTAURANT AND COMBINATION Fire District: Woodbridge GAS STATION/CONVENIENT STORE Q t. Xyes ONO Does your business handle a hazardous material in any quantity at any one time in the year? See the definition of hazardous material on the back of this form. If your answer is "No",go to Question 4. Q2. KlYes ONO Does your business handle a hazardous material,or a mixture containing a hazardous material,in a quantity equal to or greater than 55 gallons,500 pounds,or 200 cubic feet at any one time in the year? If"Yes",how long have you handled these materials at your business? 11 If "Yes",check any of the following conditions that applies to your business? ❑ A. The hazardous materials handled by this business is contained solely in a consumer product packaged for direct distribution to,and use by,the general public. ❑ B. This business is a health care facility(doctor,dentist, veterinary,etc.)and uses add medical gases. ❑ C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an agricultural or horticultural commodity. Q3. ❑Yes XNo Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. Q4. 'Yes 410 Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety 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 requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owner or Authorized Agent: Y �1�C1 tl>Wi2 Sltntat� Date Print Name Y�.SG.CGv %"'r a��`y'h Title Signature (Rev 10/96)