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COUNTY OF SAN JOF '11N <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) 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: `T�/1f� <br /> Business Owner(s) Name: Telephone: <br /> Business Address: <br /> Mailing Address(if different from above): <br /> Nature of Busit <br /> ness: Fire District: <br /> Q1. OYes 2N0 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 /> Q2. 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 /> 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 /> 03. OYes mNo Does your business handle an acutely hazardous material? See defirition on reverse side of this form. <br /> 04. OYes ONo 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 .s 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 /> Ow <br /> � / or Authorize Agent_ <br /> X2EAi? �Ql f1Jl� Je Date: <br /> X / &I - Title: <br /> Signaturb <br /> F IDEVSVC\Planning Apoi�tion Fome:'.Use Permit(Rnnsed 1-2-03) Page 6 of 9 <br />