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HA�ARDOUS MATERIALS DISCLAIMER <br /> for CA Health f Safety Code, Chapter 6.95 <br /> Business Name: USA Petroleum # 65 Phone: <br /> Site Address: 2500 W. LODI LODI CA. 96001 <br /> Street City State Sip Code <br /> Mailing Address: 1261 E 9th Street Pomona CA 91766 <br /> CITY Stat. Sip Code <br /> COMPLETE SECTION A AND B (If submitting a Business Plan, complete only <br /> Section B) : <br /> A. HAZARDOUS MATERIAL/WASTE (Check appropriate statement(s) ] : <br /> 1 . This business does not store, use, or handle any Hazardous <br /> Material or Hazardous Waste in any amount. <br /> 1_1 2 . This business does not store, use, or handle any Hazardous <br /> Materials or Hazardous waste at any one time <br /> during a calendar year in quantities equal to <br /> greater than 55 gallons, 500 pounds, or 200 cubic feet of a compressed gas <br /> r <br /> _ at standard temperature and pressure. <br /> ' ' 3 . This business does not store, use, or handle any Hazardous <br /> i_ <br /> Material in any amount other than oxygen and/or nitrous oxide for medical <br /> purposes within the office or place of business of physician, dentist, <br /> podiatrist, veterinarian or pharmacist, and maintains such gases in <br /> quantities of less than 1, 000 cubic feet for each gas. <br /> :_I 4. This business does not store, use, or handle any Hazardous <br /> Materials in any amount other than quantities packaged solely for direct <br /> distribution as a consumer product to the general public. <br /> _; 5. This business does not store, use, or handle any Hazardous <br /> Material in any amount other than quantities contained in a rail car, rail <br /> , tank car, rail freight container, marine vessel, or marine freight container <br /> for no more than 30 days. We will immediately notify Environmental Health <br /> Services of their arrival. <br /> NOTE: If none of the above apply and you have Hazardous Material/Waste, you <br /> must complete and submit a Hazardous Materials Disclosure Business Plan to <br /> Environmental Health Services. <br /> B. ACUTELY (EXTREMELY) HAZARDOUS MATERIAL (Check appropriate statement) : <br /> X; This business does not store, use, or handle any Acutely/Extremely <br /> Hazardous Materials or any mixture containing an Acutely/Extremely Hazardous <br /> Materials in any amount. <br /> ' This business <br /> _ ;_; has submitted ;_; will submit an Acutely Hazardous <br /> Material registration form. <br /> NOTE: If you have any Acutely (Extremely) Hazardous Material, you must <br /> complete and submit an Acutely Hazardous Material Registration form to <br /> Environmental Health Services. <br /> Under penalty of law, I declare that the information is true and correct and <br /> understand that County Environmental Health Services must be notified if the <br /> operations or procedures of this business change in such a way to make the <br /> above stat ement(�inaccute. <br /> Signature• \ J•—�p dam-- 9- 1 �� Date �i+ I ( 1 4 14 <br /> Print or type name. DAVID OLDFIE D Title PROJECT COORDINATOR <br /> Phone. 909.622.3424 <br /> 20 <br />