Laserfiche WebLink
COUNTY OF SAN JOAQUIN RECEIVED <br /> ; <br /> OFFICE OF EMERGENCY SERVICES FEB 2 6 2Q10, <br /> 2101 E. Earhart Avenue, Suite 300 <br /> y STOCKTON,CA 95206 SAN JOAO <br /> 36 TELEPHONE(209)953-6200 ��IOjl`j MERG{ yq 1C <br /> ilt FAX:(209)953-6268 / (l// ` J <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 and/or <br /> address in San Joaquin County is required. / <br /> Business Name:�I'cRA q 7r�j�� Lo , Telephone: ZP J-—97 3-4tcoc)I <br /> Business Site Address: Q040 W e 6-� (G41lP , -:20 CIC-10A �� A <br /> Mailing Address(if different from above): / /� <br /> Business Owner(s)Name: J3G ,`P P C � 4 Orlec-460 , Telephone: <br /> Business Owner Address: g¢/O <br /> Nature of Business: /i` Fire District: <br /> Ql. ❑Yes P�No Does your bus ness 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. []Yes E�Wo 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 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 /> ❑ 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 /> E] B. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. E]Yes 2�No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. [--]Yes [�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 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: �7 <br /> X -TSO. Date <br /> Print Name <br /> Nae/ / <br /> X " v Title <br /> Signature (Rev 8/08) <br />