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JUL. 16. 2006 2:59PM SEARS ROEBUCK & CO N0. 967 P. 3 <br /> t <br /> gat tri• COUNTY OF SAN JOAQUIN <br /> �°" •� OFFICE OF EMERGENCY SERVICES RONALD E.DALDW04 <br /> _ ROOM 610,COURTHOUSE mRECrDR OF <br /> 222 EAST wPBER AVENUE EMEROMCY OPERATIONS <br /> „p ;i• STOCKTON,CALIFORNIA 95202 <br /> TEt MWONE(209)468.3962 <br /> WARDOUS MATERIALS DWWON(209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please mad the information 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: k- M mr-r- --Pr y'8 16 Z Telephone:-Le6 —1%S-20*"63 <br /> Business Site Address: X55 1QORTRGM Dr, MMMCA i C A R ISS 3t& <br /> Mailing Address(if different fromabovcY—SE4t,� SS12 13Ev U tyl�p , M-2ta2A .1 t evrFm%. Ewan 1.0%. <br /> tao\-1 q <br /> Business Owners)Name L -S \tv(sS^ `\ Telephoner t 1 1—�`is b' 2 <br /> Business Owner Address: ���3 �E\/ rCRL�.+ \`Qtj� t-r•O^rFMAc� £S�-'ATES� <br /> Nature of Business: 1«T 41 L- Fire District: <br /> Q l. OXes L]Nb Does your business handle a hazardous material in any quantity at any one tithe in the year? See the <br /> definition of hazardous material on tate back of this form. If your answer is"No",go to Question 4. <br /> Q2. JAYes QN6 Does your business handle a hazardous material,or a mixrure 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 operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. M Yes []No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. E]Yes '®Na 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 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 a Cestificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> x Date 7 <br /> =y. �� �1�ft Name may„ 4�, e� <br /> X �� ��— Title <br /> Signarure (Roy 3/05) . <br />