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^qu q <br /> o. c <br /> t <br /> b: < <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)466-3969 <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:_i�df fLC GreyLd l �Ltr�C2 f � U� �u <br /> Business Owner(s) Name L / / ',C—!j�A Telephone: <br /> Business Address: JSZ7'�- !'� i/� S7• JYaCw Get 9Su.f <br /> Mailing Address(if different from above): <br /> /"ri <br /> Nature of Business: -E4- %�U,�✓Q(!!.� Fire District: <br /> Q1. ❑Yes t(No Does your business handle a hazardous 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. DYes VNo 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 <br /> 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 /> DA. 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 /> 11C. This business operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> / agricultural or horticultural commodity. <br /> Q3. DYes 040 Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. DYes 0No 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 of <br /> my knowledge. <br /> Owner or Authorized Ager <br /> X 'I Date: <br /> G' Title:�y <br /> Sign re ✓✓ <br /> ?0AR11(�vl/ 6407na 2 N <br />