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' Opqu,iry, c <br /> OR <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber-Avenue <br /> Stockton, California 95202 <br /> 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 name and/or <br /> address in San Joaquin County is <br /> required. <br /> "7 � �i,L Ode <br /> EI PInD�c(�,"�5oBusneseName: / <br /> Btrs'iness Owner(s)Name: <br /> Aj—z, <br /> BasineasAddress: /5 SOI C 1 L C J ZG� • lci�� C'# 1 _�� <br /> Mailing Address(if different from above). <br /> Nature of Business: STeI\;�e— nieL4"thrrL�x,. Fire District., <br /> Q1. VYes ONo Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on the back of this form. If your answer is <br /> No,"go to Question 4. <br /> i <br /> Q2. 57i'es 17 No Does your business handle a hazardous material, ora mixture containing a hazardous <br /> material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at <br /> 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 /> CJA. 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 /> 0B. 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, orharvesting an agricultural or <br /> horticultural commodity. <br /> Q3. OYes ONo Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. OYes LWo' Is your business within 1,000 feet of the outer boundary of 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 Code. <br /> 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 requirements <br /> which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury <br /> that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner orAuthon ed Agent: <br /> X ,!r %rlL/�G' Date: 7 ` % —Q Y <br /> Print Name <br /> X Title: <br /> Signature <br />