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COUNTY OF SAN JOAQUIN ' VE <br /> OFFICE OF EMERGENCY SERVICES JUL _5 20 <br /> 12 <br /> 2101 E. Earhart Avenue, Suite 300 EN <br /> W Stockton, California 95206 ..V1RON <br /> Telephone(209)953-62004lTH p MENT <br /> tiFOR�' �j Il FAX(209)953-6268 EPgRTmtWr <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business <br /> name and/or address in San Joaquin County is required. <br /> Business <br /> Name: FEDEX FREIGHT INC <br /> Business Owner(s) <br /> Name: FEDEX FREIGHT INC Telephone: 870 . 741 .9000 <br /> Business <br /> Address: 4520 S HWY 99 , FRONTAGE RD, STOCKTON, CA 95215 <br /> Mailing Address(if different from OPERATING TAXES <br /> above): P.O. BOX 840 , HARRISON, AR 72602-0840 <br /> Nature of <br /> Business: MOTOR CARRIER/LTL TRANSPORTATION SVEire District: <br /> Q1. K'es ONo Does Four 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. =as ElNo 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 200cubic feet at any one time in the year? <br /> ® If"Yes,"how long have you handled these materials at your business? <br /> =W If"Yes,"check any of the following conditions that applies to your business. <br /> W ;` DA. The hazardous materials handled by this business is contained solely in a consumer product, <br /> UJA '''' <br /> /' � packaged for direct distribution to, and use by,the general public. <br /> V! ❑B. This business is a health care facility(doctor, dentist,veterinary, etc.)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. ❑YesXWo Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. ❑Yes�Wo Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> 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 <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. <br /> I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge. <br /> Owner or Authorizey�gent <br /> X Jl✓L�r1 ;4-q Date: <br /> Print Name <br /> X DEBBIE BENNETT Title: TAX MANAGER <br /> Signature <br /> F/ApplicalionsFonns&Handouts/PlanningApplications/Business License(Revised 11-14-11) <br /> Page 4 of 6 <br />