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COUNTY OF SAN JOAt2UIN <br /> opo"I" OFFICE OF EMERGENCY SERVICES <br /> N Room 610, Courthouse <br /> ` 222 East Weber Avenue <br /> Stockton, California 95202 <br /> e Telephone (209)468-3962 <br /> '�l i'IOAN) <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: 1��J////Ucl ( fJ—Sill/2�l�� L L C <br /> Business Owner(s)Name: Telephone: s` 27 9'3/S' <br /> Business Address: C7jE/}t�Li� ,� F�6 A4 4/37// <br /> Mailing Address(if different from above): <br /> Nature of Business: Fire District: <br /> �y� <br /> Q1. ❑Yes �tJo Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> / ` definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2. ❑Yes ❑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? <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> ❑A. 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 /> ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑YesZo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes)A(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: <br /> L• '� L /% Date:_ Z X 6 <br /> Prin e <br /> X <br /> Title: <br /> a <br /> F:IDEVSVCTlanning Application Forms\Site Approval.(Revised 1-3-03) Page 6 of 9 <br />