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nRVIM. <br /> `.e • SAN JOAOU`d COUNTY Ptarhnutg[Htdt Dept <br /> OFFICE OF EdERGENCY SERVICES ESEe ..Na. <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> �lidddN\ <br /> PLEASE PRINT OR TYPE <br /> 01. Please provide a separate survey for 2.=t business name and/or address in San Joaquin County: <br /> a. Business Name: FARMINGTON FRESH SALES, LLC <br /> b. Business Owner(s) Name: See Attached Page Phone: (209) 983-9700 <br /> C. Facility Address: 7735 State Route 99, West Frontage Road <br /> Stockton, California 95209 <br /> d. Mailing Address: 1755 W. Hammer Lane, Suite 12 <br /> Stockton, CA 95209 <br /> e. Nature of Business: Fruit and Produce Sales Fire District: <br /> f. Business Lid. No: applied for Expires (MoiYr) _ Standard IndstH Code No: <br /> g. Proposed Project: Fruit and Produce Sales <br /> 02. Does your business handle a hazardous materiaR 'Hazardous Material- means any material that. because <br /> of its quantity, concentration, or physical or chemical characteristics, poses a significant present or potential hazard <br /> :o human health and safety or to the environment if released into the workplace or the environment (Includes fuels, <br /> petroleum products, paints, propane, oxygen, ammonia (EHS), chlorine (EHS), pesticides. fertilizers, and hazardous <br /> wastes...). <br /> Yes ❑ No <br /> 03. If you answered 'YES' to Question 2 above: Do you handle a hazardous material or a mixture containing a <br /> hazardous material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time? <br /> Yes ❑ No ❑ <br /> 04, Will the owner, applicant, or future building occupant handle an Acutely Hazardous Material? (List of Acutely <br /> Hazardous Materials available at the Planning Department). <br /> Yes ❑ No ❑ <br /> 05. Will proposAd building or modified f?cility he Within 1,000 feet of the outer boundary of a sr_hocl farndes K•12)? <br /> Yes ❑ No <br /> have read the Hazardous Materials Information Guide (on back page) and understand my requirements under Chapter <br /> 6.95 of the California Health and Safety Cade Sections 25505, 25533, and 25534. 1 understand that if the building does <br /> not currently have a tenant that it is my responsibility to notify the occupant of the requirements which must be mer <br /> prior to issuance of a Certificate of Occupancy. I declare under the penalty of perjury that this disclosure survey is <br /> true and accurate to the best of my knowledge and is made in the City of Stockton California. <br /> Owner or Authorized Agent: <br /> (Print) T91e Secretary <br /> ;Signature) Due Y 9 U <br /> I. San Joaquin Air P Ilunon control DlsMet 2 pfflce of Emergency services <br /> 2321 Vk Washington St_ Suite 1 )4stardous Ustartsis Division <br /> Stoektah, CA 95203 (209) 4Y-3470 322 E. Wen" Ave- Ceurthouso-Rm 610 <br /> '. IlV1C !Stockton, CA 9520th (209) 453.3969 <br /> 'OES OAT! �1217 yt <br /> !COUNTY APPROV! REJECT _, 'y'�T^IFlED _ <br /> -NCY SERVICES HUMP — RYPP — EXEHF r ✓ v.S.0192 <br />