Laserfiche WebLink
f e . <br />COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES RONALD E. BALDWIN <br />.�, Room 610, Courthouse DIRECTOR OF <br />i•I 222 East Weber Avenue EMERGENCY OPERATIONS <br />a yFoa' Stockton, California 95202 RECEIVED <br />Telephone (209) 468-3962 <br />Hazardous Materials Division (209) 468-3969 <br />MAR 3 1 2017 <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />ENVIRONMENTAL HEALTH <br />Please read the information on the reverse side before completing this survey form. A separate survey for eA%RfdkT&@RVIW <br />and/or address in San Joaquin County is required. <br />Business Name: -z C W V ^� <br />Business Owner(s) Name: 13rs���i,o�1 � LS CKfa S•ec. , Telephone: 7 �•�ft ' <br />Business Address:�j aa, .ylr"�'uttY� Qead - L� . CA QS•ai•1`l <br />Mailing Address (if different from above) <br />Nature of Business:AL <br />O Fire District: Ct�TC•R,�jy� <br />-- -- <br />Q 1. `eYes ONo Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br />of hazardous material on the back of this form. If your answer is No," go to Question 4. <br />Q2. Yes ONo Does your business handle a hazardous material, ora mixture containing a hazardous material in a quantity <br />equal to or greater than 55 gallons, 500 pounds, or 200cubic 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 />OA. The hazardous materials handled by this business is contained solely in a consumer product, packaged for direct <br />distribution to, and use by, the general public. <br />OB. This business is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical gases. <br />OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br />horticultural commodity. <br />Q3. VYes ONo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br />Q4. OYes ) 7o Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br />I 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 I own a facility or property that is used by tenants, that it is my responsibility to notify the tenants of the <br />requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br />penalty of peryury 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 Jtl 2,&ANbELl_ Date: .3%3/u17 <br />/ Name <br />X oeJ C /t ,Print .-.�P.Q-� Title: <br />Signature <br />F7,.Devsv5,Planning Application Forms Page 1 of 2 <br />Hazardous Materials Disclosure Survey (Revised 8-25-03) <br />