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JAN-02-2002 13.21 601 334 4774 P.e4/06 <br /> RECEIVED <br /> COUNTY OF SAN JOAQUtN JAN 0 2 2002 <br /> pf;RCE OF EMERGENCY SEWVICES a0t"Ar.uL oar novas <br /> ROOM 610,COURTHQUSE C0MV1ATOQMJQA(1V1ftl 000f Y t <br /> ~ 222 EAST WEBER AVENUE OMMOM M6EACY8ERVM <br /> S�OCKTON,CALIFORMA 9320: <br /> TEENGh'E(209)46b.39W <br /> p,2ARDOUS MATERIALS DIVISION R09)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> please read the information tan the reverse side beret compicting this survey form. A s Pante survey for each business name <br /> attdlor address in San Joaquin County is requite.& <br /> Business Name,_ Flying J "Travel P1aZa <br /> CFJ Properties New - bein.g built <br /> Tcicphonc:i...— <br /> Business Owner(s)Name: <br /> Business Address: <br /> 15100 Thornston Road, Lodi , CA 95242 <br /> MaiGngwddtess(ifditferentfromeltomr Suite 320, DeLo Johnson 4185 South HarrisonUgand84403eo, <br /> Nature of Business: <br /> Truck Ston with restaurant & fast food _Fire District. San Joaquin <br /> QI KlYes DNo Does your business handle a hazardous mate ial in any quantity at any ono time in the year? See the <br /> definition of hazardous maserial on the back of this form. If your answer is"No go TO Qucsuon 4. <br /> Qy, V yes 17N9 Does your business handlc a hazardous material,or a mixture conubriug a hazardous material,in a <br /> quantity equal m of grceiu Wan 55 gallons.500 pounds,or 200 cubic feet at any one limc in the ycaa 7 <br /> If"Yes".how long have you handled Ihese materials At your business? <br /> U "Yes",ebeck any of the foPov.:ng Gond:tions:hat ePplies to your business? <br /> A. The yam--dous materials handled by this business is contained solely in a consumcr product packaged for <br /> direct distribution to,and=by.the general Public_ <br /> B. This business is a health tett facility(doctor,dentist,veterinary,eteJ and OaCS 001Y medical gases. <br /> C ?itis business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricul"oral or horticultural commodity. <br /> Q3. PYes ONO Does your business hmtdle an Acutely Hazardous Material? See definition on reverse side of this form_ <br /> Q4. Dyes "6No Is your business within 1.000 feet of the pito boundary of a school(grades ft:-12)7 <br /> 1 taw read the information on this form and undeastand my requirements under Chapter 6.95 of the Califomis Ifealth and Safety <br /> Code. I understand that it I own a facility of property that is used by tenants that it is MYresPv-nsixtenants lity to notify the of <br /> the requirements which must be met Prior to i. <br /> ...of a Ccrtificaw of(kcupaccy m begmAiny of opentioss- I dechm undcr ibe <br /> penalty of perjury that the informative provided on this iliaclusurc survey is true and accurate m the best of my knowledge. <br /> Owner or AUdMr=d Agent <br /> J Phillip Adams Date <br /> June 26. 2001 <br /> X print Name <br /> Tiuc Ch of Ex, Com. <br /> X tRsr )0196) <br /> r / <br /> /" <br /> 3 •91 Raunoo urnbeor UVS eLa:60 f0 91 unr <br />