Laserfiche WebLink
ra.uIN <br /> s:` ; -cry •.t <br /> c: <br /> 9<icpaN <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 <br /> and/or address in San Joaquin County is required. <br /> Business Name:_ r L 1.F,n b e Z l2; tL 1 <br /> Business Owner(s)Name: a 15 l- Telephone: .hof 9�a VROZ- <br /> Business Address: &�X !�J %(�r G d¢' 9h 3 7 9 <br /> Mailing Address(if different from above): <br /> Nature of Business: (nth S lruc�;a v t 14ai ier- <br /> ro 6t4 ft .vlryfiFire District: 71-,z5i/ <br /> a„d f/e_l�rc.rt S-(gage_ <br /> Q1. OYes g No 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. OYes No Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br /> equal to or greater than 55 gallons, 500 pounds, or 200c 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 apply to your business. <br /> OA. 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 /> OB. 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 agricultural or <br /> horticultural commodity. <br /> Q3. OYes ONo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes ONo 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 Safety <br /> Code. 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 <br /> requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> X l/G U y✓d �7 /��f /,J- Lh s� Date: <br /> Print Name �j � <br /> X ��fA� Title: A-4f 007-IJ -L <br /> Signature <br /> F'.&MdNGVWgOUfWEMNT Mp-CpY1EgCyLL(X)C Y125 RevifB01PM0]I Paae 4 of 5 <br />