Laserfiche WebLink
' Planning/Bldg. Oepc. NODI <br /> File No. I Lc1 ld Q <br /> a� n COUNTY OF SAN JOAQUINjd� D <br /> ISd fit/ <br /> OFFICE OF EMERGENCY SERVICES RVA ROOM 610,COURTHOUSE NDINR <br /> 222EAST WEBER AVENUE AUG 2 7 1996 <br /> c.. STOCKTON,CALIFORNIA 95202 <br /> 4(�FOp�`P TELEPHONE(209)468-3962 SAN JUIN VALLEY <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 UN�FIE®A.P.C.D. <br /> HAZARDOUS MATERIALS SURVEY FORM NO, REGION <br /> Please read the Hazardous Materials Information Guide on the back side before completing this survey form. A separate form for <br /> each business name and/or address inSan Joaquin County is required: <br /> Business Name: f a C t I C as cl/ ( r04J(G/I5, <br /> Business Owner(s) Name: q b 0 Phone: 7✓3y 335z <br /> Facility Address: 3Z �• lG qy �� <br /> Mailing Address: M IE <br /> Nature of Business: g N N F Cy Fire District: Lt--�,d <br /> Ql. 61yes ❑ No Does your business handle a hazardous material? Read back Dage. If you answered"No"to Question 1, <br /> go to Question 4. <br /> Q2. 4LYes ❑ No 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? <br /> If you answered"No"to Question 2, go to Question 4. <br /> If you answered"Yes"to Question 2,do any of the following statements apply to your business?Read <br /> back Dage. <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 health care facility (i.e., doctor, dentist, veterinary...) and uses only medical <br /> gases. <br /> ❑ C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. iiXes ❑ No This business or building occupant handles an Acutely Hazardous Material?Read back nage. <br /> Q4. ❑ Yes LYNo This facility or modified facility will be within 1,000 feet of the outer boundary of a school (grades <br /> K-12). <br /> I have read the Hazardous Materials Information Guide and understand my requirements under Chapter 6.95 of the California Health <br /> and Safety Code. I understand that if the building does not currently have a tenant, that it is my responsibility to notify the <br /> occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. I declare under the penalty of <br /> perjury that this disclosure survey/exemption is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> X vH" r AG V Title V. 12. PrDdUAa ( <br /> Print AUG 9 <br /> i <br /> X Date Z <br /> SAN JOA UIN COUNTY <br /> Signatu a ��,,.- <br /> 01 ,i�'C": RGENCY SERVICE$ <br /> Rev:1N6 <br />