Laserfiche WebLink
JUL 19 2001 <br /> OMP <br /> � JOAOUIk't't?1!�m� <br /> ^'- _ <br /> COUNTY OF SAN JOAQUIN <br /> >'RR �'•. OFFICE OF EMERGENCY SERVICES RONALDLBALDWIN <br /> c .a ROOM 610,COURTHOUSE COORDCIATOR <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> •••�tCiY�VY��'• TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <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 name <br /> and/or address in San Joaquin County is required- <br /> Business <br /> equiredBusiness Name: Flying J Travel Plaza <br /> Business Owner(s)Name: CFJ Properties Telephone: New - being built <br /> Business Address: 15100 Thornston Road, Lodi , CA 95242 <br /> Mailing Address(if different from above): Suite 320DeLoy Johnson, 4185 South Harrison Blvd, Ogden, <br /> Utah 84403 <br /> Nature of Business; Truck stop with restaurant & fast food Fire District: 1T�0�41f1tt Dz L '-` <br /> Ql. hYCS ❑No Does your 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. KlYes DNo 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 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 /> D 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 /> Cl B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses only medical gases. <br /> D C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. PYes ONo Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. DYes MNo 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 1 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 Certificate 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 <br /> J Phillip Adams Date June 26, 2001 <br /> Print Name Ch of Ex. Com. <br /> X � � / Title <br /> Signature (Rev 10/96) <br /> 9 •d LZTC99111 R,4unoo uinbeor ueS eLOr60 t0 EI unr <br />