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COUNTY OF SAN JOAQUIN <br /> �? (" •� OFFICE OF EMERGENCY SERVICES <br /> rr. ry� Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> 4GIFOR�, 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 <br /> name and/or address in San Joaquin County is required. <br /> Business Name: to i <br /> Business Owner(s) Name: OM611 D0ir'1TC�11✓JUI�h/G��"•fi S 2 � Telleephone: _(/�� 61/j -67fr,0 <br /> Business Address: 175 Cf �5, ( /Cf/CS y 57r, l"10cc4o Cq g$ yy <br /> Mailing Address (if different from above): <br /> Nature of Business: Pl rQ s Fire District: <br /> Q1. OYestyo Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> 02. OYes ')(No Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at 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 /> ❑B. 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 7kNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes ANo 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 <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> � <br /> X- �� iJ C z. � <br /> - _ — -- Date:___-- it 2-$ G$� <br /> �y` P ' ame <br /> X— �—"� - -- Title: <br /> ignatura <br /> FIDEVSMPlanning Application Fortes\Site Approval.(Revised&OM4) Page 6 of 9 <br />