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i • 7 <br /> PA - 0700551 <br /> y COUNTY OF SAN JOAQUIN <br /> ,oA u(�y'..• OFFICE OF EMERGENCY SERVICES RECEIVEo <br /> r.` T '• Room 610, Courthouse <br /> w < 222 East Weber Avenue <br /> Stockton, California 95202 DEC -3 2V <br /> °' • ;:" Telephone (209) 468-3962 OFRCEOF bAIV JUHUUIN UUUN I <br /> LIFO <br /> Hazardous Materials Division (209) 468-3969 EMER®ENCYSERWCES <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 <br /> name and/or address in San Joaquin County is required. <br /> Business Name: Cozad Trai 1 er Sal es, LLC <br /> Business Owner(s)Name: Tom G. Pi stacchi o k= J— o H N}9�(1 Ane: 209-931-3093 <br /> Business Address: 4907 Waterloo Road, Stockton, CA 95215-2096 <br /> Mailing Address (if different from above): Same <br /> Nature of Business: Manufacturing / Sales Fire District: Waterloo - Morada <br /> Q1. h6les ONo 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. 29Yes ONo 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 200cubic fegt at any one time in the year? <br /> If"Yes," how long have you handled these materials at your business? 3 ears <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, <br /> packaged for direct 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 <br /> agricultural or horticultural commodity. <br /> Q3. OYes R[No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes ®No 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 <br /> 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 <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I <br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best <br /> of my knowledge. <br /> Owner or Authorized Agent: r <br /> X X 0 S4 Date: 1 <br /> N e /� <br /> X Title: U \�' \C -e r- <br /> Signature <br /> F:\DEVSVC\Planning Applicagon Forms\Site Approval.(Revised 6-03-04) Page 6 of 9 <br />