Laserfiche WebLink
COUNTY OF SAN JOAUUIN <br /> zdl <br /> o"°"I" OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> `` ca Telephone (209) 468-3962 <br /> q�IFpR� <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: Z- FA RI'`I P R0 D U C E <br /> Business Owner(s) Name: SAr1AD A-2-1-2— Telephone: ZOG1-g3Z-50 1 <br /> Business Address: S (�E E E RD Rte`C I/ C A <br /> Mailing Address (if different from above): SSM 1�_r - <br /> Nature of Business: G�L�LV 1-� V C� GTON-'F� Fire District: <br /> Q1. ❑Yes leo definioes tion off our business <br /> hazardous material onr he back of this form quantitys material in any If your an we No,"go to Quest on 4e he <br /> Q2. OYes I%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 hazardousmaterials <br /> by this and use business <br /> he general red s solely in a consumer product, <br /> packaged for direct <br /> OB. This business is a health care facility (doctor, dentist, veterinary, etc.)and uses onIV 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. ❑Yes f�(No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes MNo Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> operty that is used by tenants, that it is my responsibility to notify the <br /> Safety Code. I understand that if I own a facility or pr <br /> tenants of the requirements which must be met prior o is roa ded once ofaCertificate <br /> this disc osu eoccupancy <br /> sctrue and o accurate beginning at of he best <br /> declare under the penalty of perjury that the information p <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> X S�.M�� A\-L \_7_ Date: 4 - 3D ' �rJ - <br /> Print Name _ Title: N tom` <br /> X -_ <br /> Signature <br /> F inFVSVC\P12nnina Application Form-,\{k"_Permit (Revised 1-2-03) <br /> Page 6 of 9 <br />