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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> I <br /> "Room 690, Courthouse <br /> 222 East Weber Avenue <br /> Sto'kton;Califomia 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 andlor <br /> address in San Joaquin County is required <br /> Business Name: C <br /> h <br /> iepon <br /> Business Owner(s)Name: re / 7 <br /> Business Address: ��f�a � <br /> zy <br /> Mailing Address(if different from above):. <br /> E Nature of Business: �/ CZ District: <br /> i <br /> 1 <br /> Q1. 0Yes �Wo Does your'business handle a'hazerdous 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 /> Q2. aYes P(Vo Does your business handle a,hazardous material,or a mixture containing a hazardous <br /> material in a quantity equal,to or greater than 55 gallons, 500 pounds, or 200cubic feet at j <br /> any one time in theyear? <br /> If"Yes,'hqw long have you handled these materials at your business? <br /> If'Yes,"check any of the following conditions that applies to your business. <br /> I <br /> I <br /> L7A. The hazardous materials.har'idled by this business is contained solely in a consumer product packaged for <br /> direct distribution id,and use by, the general public. <br /> L7B. This business is a healt�aare facility(doctor, dentist, veterinary, etc.)and uses oniv medical gases. <br /> i <br /> LM. This business operates`a farm forpurposes of cultivating the soil, raising, or harvesting an agricultural o <br /> horticultural commodity. <br /> Q3. C1Yes 40 Does your business handle an acutely hazardous_ material? See definition on reverse <br /> side of this form. <br /> Q4. Yes L7No Is your business within 1,000 feetof the outer boundary of a school(grades K-12)? <br /> I <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 l 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. l declare under the penalty of perjuy <br /> that the information provided on this disclosure survey Is true and accurate to the best of my knowledge. i <br /> Owner or Authorized Agent: <br /> X Dale: <br /> X Title: Z,_,57IlS <br /> ignature <br /> i <br /> r <br /> 4 <br /> I , <br /> L � , <br /> k <br /> GPAPP FORM REV.+4"2 RHO) <br /> - .. V <br /> r <br />