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City Bldg Dept : i Apeation# 15(jp 55 COUNTY OF SAN JOAQUIN a• OFFICE OF EMERGENCOtER}L[C8S ,ED RONALD E.BALDWIN ROOM 610,COURTHO SE v '°�D ' o 222 EAST WEBER AVENUE i Q u 2007 REb D I V E D .., STOCKTON,CALIFORNIA�34b2 ,�rPOa~ TELEPHONE(209)466-3963AN JUAUUIN UUUN I Y `+t�^ HAZARDOUS MATERIALS DIV18IME PEW BOA1CYSEFMCES JAN 2 7 2`0 HAZARDOUS MATERIALS SURVEY FORM SJVAPCD NORTHERNREGION 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 County is required. 7 Business Name: PAUFIG Lo/rST r2C1`Dt)&0V-5 Business Owner(s)Name: -a(-t Ft�- f pl—i ' ?W)10 c5C61 -Telephone: C c�10� 733/ Business Address: 741 1 STbGtC.TrtJ $T L.6aI , (-A, 9SZy0 Mailing Address(if different from above): Nature of Business: C"tjyz Y Fire District: LoD I Q 1. Wus�es []No 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. (Wes 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? 3 Zi !Xca rS 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 pply medical gases. ❑ C. This business operates a farm for purposes of cultivating the soil, raising,or harvesting an agricultural or horticultural commodity. Q3. E es ❑No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. Q4. ❑Yes QNo 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 M r VU, G✓N�� Date / Print Name � % Title /a .c Signature Aev 10/96)