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COUNTY OF SAN JOAQUIN <br /> .Fe.y OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton. California 95202 <br /> Telephone (209)468-3962 <br /> r7<%[ONS`• <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 /> B & DInc. <br /> Business Name <br /> ROBERT E HEISLER 2098324802 <br /> Business Owneris)Name: _ Telephone: <br /> 26955 S Hansen Rd,Tracy CA 95377 <br /> Business Address <br /> Mailino_ Address(if different from above): _ <br /> CONSTRUCTION OFFICE TRACY <br /> Nature of Business Fire Distract <br /> ]1- OYes ONO Does vour business handle a hazardous material in anv 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 /> 02. OYes ONO Does vour 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 anv One time in the year? <br /> If "Yes."how long have you handled these materials at your business?---- <br /> If <br /> usiness? __If "Yes."check any of the following conditions that applies to your business. <br /> OA. 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 /> OB. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases <br /> 0C. This business operates a farm for purposes of cultivating the soil.raising. or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. ❑Yes ONO Does your business handle an acutely hazardous material? See definition on reverse side of this form <br /> 04. OYes ONO Is your business within 1.000 feet of the outer boundary of a school(grades K-12)? <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health an(! <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 Occuoancv 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 /> DALE A COSE _ <br /> X Dare <br /> Print Name Applicant <br /> X — --- — Title:-- <br /> Signature <br /> FCEVSVCP amri App,k=nFamirSde App,nval. IRa1sc009-10.091 Pape6ofp <br />