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` COUNTY OF SAN JO. AN <br /> OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue, Suite 3-- <br /> Stockton, California 95202 <br /> Telephone (209) 953-6200 <br /> Fax (209) 953-6268 <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 /> nacre and/or address in San Joaquin County is required. <br /> Business Name: Quality packing 6 Shipping <br /> Business Owner(S)Name: Jack Bozsano Telephone: 209-467-8320 <br /> Business Address: 6880 Navone Rd., Stockton, CA 95215 <br /> Mailing Address(if different from above): <br /> Nature of Business: Agricultural Packing Fre Disbict:Waterloo—Morada <br /> Q1. OYes MNo 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 ONo 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 /> Q3. OYes ONo Does your business handle an aeutdv hazardous material? See definition on reverse side of this form. <br /> 04. OYes ®No 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 Auporized Agent: <br /> x J O Date: ' P-"n <br /> X Print Na Title: <br /> ign re <br /> F:%DEvsvcW%nnhQ Appicauon Forna%Sft Approval.(Revised 02-03-10) Page 6 of 9 <br />