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RECEWEL <br /> APR 0 6 2013 <br /> ENVIRONMENTAL HEALTH <br /> �aau <br /> COUNW OF SAN JOAQUIN PERMITISERVICES <br /> -Ef-P OFFICE OFEMERGENCY SERVICES RONALD E.BALDWIN OF <br /> Wir­ <br /> Telephoate <br /> Room 610,Courthouse Duscrot:OF <br /> J. 2)2 East Weber Avenue a trxxc Ncr oFsaAnoNs <br /> Stockton,Calfanra 93242(209)-068-3962 <br /> Hazardous Materials Division(209)465-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate sut-vey for each business name <br /> and/or address in San Joaquin County is required. <br /> Business Name: Waterproofing Associates Inc <br /> BusineasOwncr(z)Name: Dennis Ryan and 4tava math Telephone: 650-937-1299 <br /> Business Address: 1211 East Vine Street Lndi ra �ag <br /> Mailing Address(if different from above): 975 Terra Bella Avenue MOUnLdin 17,.ew CA 04043 <br /> NatureofEusiness: Commercial Roofing Contrartnr FireDisuict <br /> Ql. Dyes DRo Does your business handle a hazardous material in in the year? See the definition <br /> of hazardous material on the back of this term. If your answer is No;"Soto Question 4. <br /> Q2. Dyes &No Does your business handle a hazardous material,ora mixture containing a hazardous material in a quantity <br /> equal to or greater[ban 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 contaiMed solely Sha consumer product,packaged for direct <br /> distribution to,and use by,the general public. <br /> DB. 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. Dyes DNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4, Dyes Wo 15 your business within 1,000 feet of the outer boundary ora school(grades K-12)? <br /> I have read the information on this form and understand my requirements under Chapter 695 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 perjury that the information provided on this disclosore survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent <br /> 7; Steve Nash <br /> Date. March 18 2015 <br /> — * Title, Vice President & Owner <br /> X <br /> r.(Devsyskftnning Application Forms Pagel oft - <br /> ljyardous ataterWs Disrlmre Survey(Rev Jed 5-25-03) <br /> i <br />