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r �X JUL 16 200.1 V COUNTY OF SAN JOAQUIN �'y�uq�ultu °!amu "a'Pc OFFICE OF EMERGENCY SERVICES R >} COI1P.r Y 'f*ft NCYSERVICE < ROOM 610,COURTHOUSE DIRECTOR OF 222 EAST WEBER AVENUE EMERGENCY OPERATIONS • c.., `P.� STOCKTON,CALIFORNIA 95202 TELEPHONE(209)468-3962 - HAZARDOUS MATERIALS DIVISION(209)468-3969 HAZARDOUS MATERIALS DISCLOSURE SURVEY 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/Coouunty is required. Business Name: oCty t G�••``1, ��z ��/ C G 7 7 I /Nl�� FPr(,) � 1 c5 Zl L` ' Tele hone: � ( � /al/1r Business Owner(s)Name: P Business Address: 3x35 �Pn6 / Mailing Address(if different from above): Nature of Business: 41&2El�DOaE � Fire District: Ql. /Yes 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. 4es 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? 12 �a3 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 only medical gases. ❑ C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an // agricultural or horticultural commodity. Q3. 111Yes ❑No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. Q4. ❑Yes �Io 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: X ( }i Date Print Name X Title ?�s lL en- Signature