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COUNTY OF SAN JOAQUIN <br /> Pa`''" OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> t Stockton, California 95202 <br /> •�'�(/Fo `P•• 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 <br /> name and/or address in San Joaquin County is required. <br /> Business Name- Lost Isle <br /> Business Owner(s) Name: Lost Isle Partners — Telephone: 408-242-6122 <br /> Business Address: 11050 Acker Island, Stockton CA 95219 <br /> Mailing Address (if different from above): 4555 N. Pershing Ave #33-211, Stockton CA 95207 <br /> Nature of Business: Resort Fire District: <br /> Q1. E*es ONo 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. Coles ❑No 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 feet at any one time in the year? <br /> If"Yes," how long have you handled these materials at your business? Propane, 15+ years <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> . 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 /> ❑B. 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 /> 03. ❑Yes ENlo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> 04. ❑Yes E*o 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: 1/pQ <br /> X Date: 0 LO 105 <br /> Pri Name <br /> X Title:_ O �.J A/.2ln. C2 e. <br /> Signature <br /> F\DEVSVC1Pianning Application Forms\Entertainment Permit.doc Page 7 of 10 <br /> .!Revised 05-09-I1RN <br />