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Planning/Bldg. Dept. <br /> Fite No. <br /> apa�,n COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD R.BALDWIN <br /> = i ROOM 610,COURTHOUSE COORDINAT <br /> N: :t <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 D LS l% l5 <br /> c tiod— TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 1 1 1996 <br /> HAZARDOUS MATERIALS SURVEY FORM <br /> Please read the Hazardous Materials Information Guide on the back side before completing this sury y fo ; pg �pES <br /> each business name and/or address in San Joaquin County is required: <br /> ORE <br /> each <br /> Business Name: _��/ei e 2`T c��P-,W fi e <br /> Business Owner(s) Name: h�3 T C.�s.-r C�Phone: <br /> Facility Address: e5Z5 3 w95 A(2xr-maep <br /> Mailing Address: Z9,2, P7 ,Lpde i2lF 1alL' 614 FS-r667 <br /> L i <br /> Nature of Business:,,��0Tpid% j 't`-T/,�>I�/i llU4/�✓ Fire District: /fix✓df�ve <br /> Ql. Uk Yes ❑ No Does your business handle a hazardous material? Read back page. If you answered"No"to Question 1, <br /> go to Question 4. <br /> Q2. a"Yes ❑ No 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? <br /> If you answered"No"to Question 2,go to Question 4. <br /> If you answered"Yes"to Question 2,do any of the following statements apply to your business?Read <br /> back Daee. <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 health care facility (i.e., doctor, dentist, veterinary...) and uses only medical <br /> 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 CrNo This business or building occupant handles an Acutely Hazardous Material?Read back page. <br /> Q4. ❑ Yes UY No This facility or modified facility will be within 1,000 feet of the outer boundary of a school (grades <br /> K-12). <br /> I have read the Hazardous Materials Information Guide and understand my requirements under Chapter 6.95 of the California Health <br /> and Safety Code. I understand that if the building does not currently have a tenant, that it is my responsibility to notify the <br /> occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. I declare under the penalty of <br /> perjury,that this disclosure survey/exemption is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent ) <br /> X �/J!i� (,�.GC/�US Title �2C�2/ /.LKc54Qv/� <br /> c c o <br /> Print <br /> X �__ Cil��z_o� Date Q <br /> Signature <br /> Rev:1/96 <br />