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r.' <br /> c <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> TelephoneJ209) 468-3962 <br /> Hazardous Materials Division (209)468-3969 <br /> HAZARDOUS MATER: ,LS 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: ^'/A/�L 5-/0 /t/ /F/r/f n �i <br /> Business Owner(s) Name: f--/ /Q/Q.7LZ /I Telephone: 20 y <br /> Business Address: 74moA (7!9'�>� — <br /> Mailing Address (if different from above): PO do 6 -� "3 7 C� 7 <br /> Nature of Business:—. -e/V <br /> ���i'fi�-/3�� /�A Fire District: /� �$'C/1 Z!9 A,1 <br /> 01. Dyes W5 o 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. Dyes ®'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 of the following conditions that applies to your business. <br /> DA. 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 /> DB. This business is a health care facility(doctor,dentist,veterinary, etc.)and uses only medical gases. <br /> DC. This business operates a fans for purposes of cultivating the soll, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. Dyes IHfJo Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. Dyes C01Qo 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 /> 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 of <br /> my knowledge. <br /> Owner or thorized Agent: <br /> X Data: Z4 <br /> tint � e y' <br /> X Title: <br /> Signature <br />