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la--•�'� Afi <br /> r.' z <br /> w: <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.J209) 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 <br /> name and/or address in San Joaquin County is required. <br /> Leonard & Company , Inc . <br /> Business Name: <br /> Business Owner(s) Name: Fred Wilhelm President Telephone: 40R—QSR-17 /,Q <br /> Business Address: 2001 Tarob Court Milpitas Ca 95015 <br /> Mailing Address (If different from above): <br /> Nature of Business: Fire District: <br /> Q1. ❑Yes ?d 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. OYes C$No 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 /> 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 /> OC. This business operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes (QINo Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. - <br /> 04. OYes ®No 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. 1 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 pflor 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 Agent: <br /> X Georgio Perry Data: 1-14-04 <br /> Print Name <br /> X Title: Director Business Site Development <br /> Signature <br />