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r :r =�_ �• 3 SAN JOAQUIN COUNTY PC rang H D <br /> OFFICIO OFEMERGENCY SERVICES '" a'`'" t? <br /> 't 111HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> "fir <br /> �LIR0Ra <br /> PLEASE PRINT OR-TYPE F <br /> ai. Please provide a separate survey for aach business name and/or address in San .loaquin County: <br /> KRC Aggregate, Inc. <br /> a. Business Name: 8gre g <br /> b. Business Owner(s) Name: Knife River Coal. Mining Company Phone; 701-223-1771 <br /> c. Facility Address: 24717 East Brandt: Road <br /> Lodi, California 85240 <br /> F1d. -Mailing Address: P.O. Box 746 <br /> Clements, CA 95227-0746 <br /> e. Nature of- Business: aggregate miningFire District: Clements Fire <br /> f, Department <br /> f. Business 'Uc. No: 01484 Expires (MofYr) 6/23/9 Standard indstri Code No: 1442 <br /> �t g.. Proposed Project: addition of 10 acres for aggregate minin <br /> �-~ 02. Does your business handle a hazardous materfaR -Hazardous Miterfal" means any material that. because__ <br /> ! of 'its quantlty; concentration, or physical or chemical characteristics, poses a significant present or potential hazard <br /> to human health and safety or to the environment if released into the workplace or the environment. (Includes fuels. <br /> petroleum products, paints, propane, oxygen. ammonia (ENS), chlorine (FHS), pesticides, fertilizers, and hazardous <br /> Fiwastes...). <br /> Yes ® No ❑ <br /> 03. If you answered 'YES" to Question 2 above: Do you handle a hazardous material or a mixture containing a <br /> hazardous material in a quantity equal to or greater than 55 gallons-, 500 pounds, or 200 cubic feet at any one tine? <br /> Yes Q No ❑ <br /> 04. Will the owner, applicant, or future building occupant handle an Acutely Hazardous Material? (List of Acutely <br /> Hazardous Materials available at the Planning Department). <br /> I F Yes ❑ No <br /> Q5. Will proposed building or modified facility be within Z,000 feet of the outer boundary of a schoof (grades K•12)? <br /> i Yes El No <br /> l have read the Hazardous Materials information Guide (on'back page) and understand my requirements under Chaptsr <br /> F <br /> , 6.95 of the California HeaM and Safety Code Sections 25505, 25533, and 25534. 1 understand that If the building does <br /> i' not currently have a tenant: that it is my responsibility to notify the occupant of the requirements which must be met <br /> prior to issuance of a Certiflcate of Occupancy. 1 declare under the penalty of perjury that th disclosure survey is <br /> F, true and accurate to the best of my.knowledge and is made in the City of Lodi California. <br />{ Owner or Authorized Agent: <br /> (Print) Davi Flegqer, Aenior Vice President and General Manager T1W <br /> ;S[gnaturil dale <br /> A <br /> 1. San Joaquin Air Potluttaa centro[ fllstrlct 2. ottice of Emergency larylcsa <br /> (aaa•'� 2321 Nft Washington St' lults 1 Nae■rdaus flat*rials Dtrlslan <br /> F Stock?" CA 93243 (204) 4"s_U7o 222 Ea <br /> _ wear Ara– Courrhour�-RM 610 <br /> I \ Stockton, CA 95242 (209) 462 3969 <br /> 089 IHSP OATIr t�1 <br /> APPROVE� RUECT VERIFIED <br /> HPJUP — RUPP EXEUP-T T V.S.0192 <br />