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Vt �$; <br />■ VJX <br />AdA�4xr1!\ <br />Q 1'? hN'Tlease provide a separate stirvey;#c <br />y�r �-..aunt <br />t.. <br />a.' Bus es's Name: <br />:�. <br />b `Mailing Address: i <br />;i <br />cWJFacility Address: 1_LA <br />d, Contact Name: K CC <br />e. Nature of Business:_ <br />,f. Proposed Project: <br />sCI,OSURE SURVEY EN <br />'. }fir <br />I <br />s name and address in San. -Joaquin, <br />r <br />A O Phone: 8 3—SZS <br />I <br />Com• .- x-15 <br />3 <br />Q2. Will the owner, applicant or future building occupant handle a hazardous material? <br />(Includes gasoline, oil, propane, oxygen, acetylene, ammonia, chlorine, pesticides, ... ) <br />Yes 0 No <br />Q3. Will the owner, applicant or future building occupant handle an Acutely Hazardous Material? <br />(List of acutely Hazardous Materials available at the Planning Department) <br />Yes ® No <br />Q4. Will the proposed building or modified facility be within 1,000 feet of the outer boundary of <br />a school (grades K - 12)? <br />Yes No <br />I have read the Hazardous (Materials Information Guide (on back page) and understand my <br />requirements under Chapter 6.95 of the California Health and Safety Code Sections 25505, <br />25533, and 25534. I understand that if the building does not currently have a tenant, that it is <br />my responsibility to notify the occupant of the requirements which trust be met prior to issu- <br />ance of a Certificate of Occupancy. <br />Owner or Authorized Agent: (Print) QCK-WCAL <br />Date:=)I _ (Signature) <br />(office Use Only) <br />1. Son Joaquin Hir Pollution Control District <br />1601 lost Hazelton Street <br />Stockton, CH 95205 <br />(209)468-3470 <br />2. Son Joaquin County DES <br />222 lest Weber Ruenue, <br />Room 610 <br />Stockton,CH 95202 <br />(209)944-2116 <br />1.8 <br />