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Y: S COUNTY OF SAN JOAQUIN OFFICE OF EMERGENCY SERVICES Room 610, Courthouse 222 East'Weber Avenue Stockton, California 95202 Telephone,,(209) 468-3962 Hazardous Materials Division (209) 468-3969 HAZARDOUS MATERIALS DISCLOSURE SURVEY I Please read the Information on the reverse side&fore completing this survey form. A separate survey for each business name and/or address In San Joaquin County is required. Business Name: GhPcNITE C oNU` T(iil flnN CO��f'f NY Business Owner(s) Name: rf PsNIZECIhJST r�J-NCO ^fl�oYTelephone: 02419- fl&2- Business Address: C�, It1AfiL1'VJ f11-01^Y3 r7�6Nr' I GPdYIj' q r,2;t1 Mailing Address (if different from above): F.0, t0A ISI STOCfC" ON ,c.A X520 I Nature of Business:i�AVYG's�� -!nN� A3 �_Fire District: ]� rTMP, GO>`r C jLETE hM7 1 AL�hL-G�. Q1. ■Yes ❑ No Does your business handle a hazardous material In any quantity at any one time in the year? See the definition of hazardous material on the back of this form. If your answer is No,-go to Question 4. Q2. LYes 0 No Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at any one time in the year? If"Yes; how long have you handled these materials at your business? I�1� If"Yes,"check any of the following conditions that applies to your business. ❑A, The hazardous materials handled by this business is contained solely in a consumer product, packaged for direct distribution to, and use by, the general public. ❑B. This business Is a health care facility(doctor, dentist,veterinary, etc.) and uses only medical gases. ❑C. This business operates a farm for purposes of cultivating the soli, raising, or harvesting an agricultural or horticultural commodity. Q3. ❑Yes ■No Does your business handle an acutely hazardous material? See definition on reverse side of this form. Q4. ❑Yes ■No Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety Code. 1 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 which must be mel prior to Issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owner or Authorized Agent: X Date: 1CIL, 2�, 2,Co2 Print X Title: Signa ure