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<: X <br /> Y1: :< <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) 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 name and/or <br /> address in San Joaquin County is required. <br /> Business Name: ��L/�D2ti'/4 �������7 Af 4f <br /> Business Owner(s)Name: iCltils L 0'('4:f�ZTelephone: <br /> Business Address: <br /> Mailing Address(if different from above): <br /> Nature of Business: �G��i c-CcSoiZ Fire District: <br /> Q1. LOTes O 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. Lwe"s L7 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 ofthe following conditions that applies to your business. <br /> LX The hazardous materials handled by this business is contained solely in a consumer product, packaged for <br /> direct distribution to, and use by, the general public. <br /> L7B. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. <br /> at . This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3. AWes L3No Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. L7Yes L9No Is your businss within 1,000 f et of the outer boundary of a school(grades K-12)? <br /> I have read the information on this form nd understan my requirements under Chapter 6.95 of the Califomia Health and Safety Code. <br /> I understand that If I own a facility or property that is yrsed by tenants,that it is my responsibility to notify the tenants of the requirements <br /> which must be met prior to Issuance of a Certif/cat 'of Occupancy or beginning of operations. I declare under the penalty of penury <br /> that the information provided on this disclosure survey Is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> X �`1i(//�y /1Z�i�J7� Date: /Z —12— <br /> P <br /> X Title: <br /> Signature <br /> I <br /> UPAPP FORM REV.0-15-02(IHD) 6 <br />