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r COUNTY OF SAN JOAQUIN OFFICE OF EMERGENCY SERVICES RONALD E.BALDWLN 2101 E.Earhart Avenue, Suite 300 DIRECTOR OF "= Stockton, California 95206 EMERGENCY OPMATIONS a Telephone (209) 953-6200 FAX (209) 953-6268 HAZARDOUS MATERIALS DISCLOSURE SURVEY' Please read the infon nation on the reverse side before completing this survey form. A separate survey for each business name and/or address in Sar J Daquin County is required. Business Name: s i w. Business Owner(s)1,,aj ne:- Telephone: Sa� l Business Address: P Mailing Address(if erent from above): r 1� Nature of Business: D 1 imo Fire District: Q1. Wes ❑No E on your business handle a hazardous material in any quantity at any one time in the year? See the definition orliazardous material on the back of this form. If your answer is No,"go to Question 4. Q2. ❑Yes No o s your business handle a hazardous material,or a mixture containing a hazardous material in a quantity e ji Lai to or greater than 55 gallons,500 pounds,or 200cubic feet at any one time in the year? I `Yes,"how long have you handled these materials at your business? I "Yes,"check any of the following conditions that applies to your business. ❑A. 11ir hazardous materials handled by this business is contained solely in a consumer product,packaged for direct distribution to,and use by,the general public. 5 ❑B. 11ils business is a health care facility(doctor,dentist,veterinary,etc.)and uses only medical gases. ❑C. s business operates a farm for purposes of cultivating the soil,raising,or harvesting an agricultural or t"ticultural Commodity. Q3. 0Yes PNo s your business handle an acuter hazardous material? See definition on reverse side of this form. Q4. ❑YesNo s your business within 1,000 feet of the outer boundary of a school(grades K-12)? I have read the info ation on this form and understand my requirements under Chapter 6.95 of the California Health and Safety Code. I understand at if I own a facility or property that is used by tenants,that it is my responsibility to notify the tenants of the requirements w h must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of peri that the information provided on this disclosure survey is true and accurate to the best of my knowledge. AJ(9 SJ�4 L tit,- W, T-WlIota Vi,P�' .Zt-�- IU U rlAi-, 4-r Of S<1V Owner or Authori Agent: X Date: -- t Name X Title: i ture V.nr-VRVl:lCiwnnino A on Forms\ 'age 14 of 15 ;