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r.' s <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. p I <br /> Business Name, wd �sc Mc a-avte R Ly- j �-j r),- PV�'k'�� 0 5¢4/ <br /> Business Owner(s)Name: Telephone: <br /> Business Address: v a ,�• !� h " 57�k� C A . 2T -2Z <br /> 1 <br /> Mailing Address(if different from above): <br /> i <br /> - <br /> Nature of Business: �1 re. Dev�c�.�" tn'1�-N� Fire District: <br /> Q1. OYes 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. r7Yesi0o Does your buslness 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 /> 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 /> 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 agricultural or <br /> �( yyy\''' horticultural commodity. <br /> Q3. esfo Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> 04. OYes *o 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 Safety Code. <br /> I understand that if I own a facility or property that Is used by tenants, that it is my responsibility to notify the tenants of the requirements <br /> which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury <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 4\l (dJ Date: <br /> Print N <br /> X <br /> Q�� c,!lA� c <br /> Title, i :�A c <br /> Signature <br />