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1 l ` SAN JOAQUIN COUNTY <br /> c. <br /> •� OFFICE OF EMERGENCY SERVICES <br /> cr, sPnringlBldg ppt » <br /> �* HAZARDOUS MATERIALSURVEY7. <br /> S DISCLOSURE <br /> p°p,+ <br /> P11 EASE. PRINT oR_� <br /> D1• Please provide a separate survey. y for aach business name and/or address in San Joaquin County; <br /> a• Business ^Name; <br /> Stock on 0 en- Air Mall _ <br /> b• Business Owner s <br /> ( ) Name: Stockton Open Air Mall <br /> G. Facility Address: 3550 N. Wilson Way Phone: (209) 465-1544 <br /> Stockton, OA �lSLO� <br /> d• Mailing Address: <br /> e Nature of Business: Ope1i Air Mall, . <br /> f• Business Uc. No: Fire District: City of Stockton <br /> N/A Expires (Mo/Yr) N <br /> 9 Proposed Project: Include a bingo parlor. at the existStandard <br /> to dor AirstMall, <br /> No: N_ <br /> /A <br /> Q 2. Does your business handle a hazardous material? -Hazardous <br /> Of its quantity, concentration, or physical or chemical characteristics o Material" <br /> to human health and safety or to the environment if released into the workplace means any material-that. because <br /> . p es a significant present or potential hazard <br /> Petroleum products, paints, propane, oxygen, ammonia p or the environment. (Includes fuels, <br /> wastes...J. (EHSJ, chlorine (EHS), pesticides, fertilizers, and hazardous <br /> Yes ❑ No X❑ <br /> Q 3• If you answered 'YES' to Question 2 above: <br /> Do You hazardous material In a quantity equal to or greater than 55 gallons, 500 Pounds,e a sor 200material or a mixture containing a <br /> Yes ❑ No a200 cubic feet at any one time? <br /> 04. Will the owner, applicant, or future building <br /> Hazardous Materials available at the Planning Department)ant handle an Acutely Hazardous Material? <br /> (list of Acutely <br /> Yes ❑ No �] <br /> O5. Will proposed building or modified facility be within 1,0o0 <br /> Yes feet of the outer boundary of a school (grades K-12)? <br /> I have read the Hazardous Materials Information Guide (on back page) and understand <br /> 6.95 of the California Health and Sale my requirements under Chapter <br /> not currently have a tenon ry Code Sections 25505, 25533, and 25534. <br /> that it is'my responstbili I understand that if the building does <br /> Prior to issuance of a Certificate it Occupancy. ry to notify the occupant of the requirements which �-- <br /> true and accurate to the best of my know age•and iscmade n tite C'ry of '""' be me[ <br /> lare under a Penalty of perjury that this disclosure survey <br /> California. <br /> Ownar or Authorized Agent: <br />(Print) is .: ..: jr.i _ ::int:c.::�' •rt: �.. <br /> The <br /> Signalurs) , <br /> Data C <br /> / (--_� <br /> San Joaquin Air Pollutlon Control Dlatrlct <br /> 2321 Vii Washington St. suits 1 2• OHIce of Emergency services <br /> 310ck10h• CA 25203 (709) 464-34170 laHazardous sterlals Division <br /> 222 E. Weber Ave_ Courthous.-Rm 610 <br /> Stockton, CA 95202 (209) 499-3969 <br /> OES INSP DATE <br /> APPROVE REJECT <br /> VERIFIED <br /> HUMP <br /> RLIPP cvc­.,,. <br />