Laserfiche WebLink
q,4�4N <br /> Qry �o.�.coc <br /> RECEIVED <br /> 65 <br /> COUNTY <br /> COUNTY OF SAN JOAQUIN <br /> SEP 2 2 2008 <br /> OFFICE OF EMERGENCY SERVICES SAN JOAQUIN COUNTY <br /> Room 610, Courthouse OFFICE OF EMERGENCY SERVICES <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> Telephone(209)468-3962 <br /> Hazardous Materials Division (209)468-3969 <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 name <br /> and/or address in San Joaquin County is required. <br /> Business Name: (_,D3�a,4 J rcu le r <br /> Business Owner(s) Nam�e__ ylDo–\/td � �&Jl o WQy I Telephone:o7 <br /> // 9 %L 3013 <br /> Business Address: TGU7 5a&—Idy . kTDT <br /> Mailing Address(if different from above): <br /> Nature of Business: +al tl- ►4't. At c.`iclikrl r4 Fire District: <br /> Q1. Yes 0 No Does your business handle a hazardous material in any quantity at anyone time in the year. Seethe <br /> definition of hazardous material on the back of this form. If your answer is"No,"go to Question 4. <br /> Q2. OYes1 No Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br /> equal to or greater than 55 gallons, 500 pounds, or 200c 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 apply to your business. <br /> OA. 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 /> 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. []Yes ANO Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes KNo 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 perjury 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 ( r Q 1 Date: <br /> tName <br /> X Title: O�L <br /> Si nature <br /> F)SUILOINGW 14DOUTSARCHIVEPRIOR TO2NIINPERMITAPP-COMMERCIALFile N125Coc Page 4 of 5 <br /> (Rei 02-2948) <br />