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<br /> SAN JOAQUIN COUNTY Pfanningll3i g peP�- ,, r
<br /> OFFICE OF EMERGENCY SERYtCES F1144,Nag' �-; �••��
<br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY
<br /> ' Met-
<br /> al Please provide a separate survey for business nam* and/or address in Sat Joaquin County,
<br /> a Business. Name: ._D,._ .t ear , o
<br /> ' Ia Business Owner(s) Name: ,,,'��rla_f/.d d- 7� s.i����ur,yPhona:W4/--P
<br /> c Facility Address L/ er
<br /> ' d Marling Address
<br /> a Nature of Business �Flrtir Dlstrlci:
<br /> f Business Lic No. Expires (Mo/Yr) Standard Indstri Code No
<br /> ' g Proposed Protect.
<br /> h If the business Is ogt in apeCalion, when is the approximate data of operation?
<br /> '
<br /> ,4,r4;10
<br /> 02: Does your business handler ar harantom rrtarrrrs Hx=rd&us-_Mxiwis4'",meaw any mw*rW that bo=um
<br /> at it&guanuty, concentraWN or phys+cak-*n,*vmieak charaClWsws. posma,so pgrd te
<br /> pnrsenl or pontlal ha.zarc
<br /> ' to human health and safety or to the environment if released into the workpiace or the environment. (Includes !iris,
<br /> petroleum products. paints, propane, oxygerL ammonia (AHM). chlorma (AHM). pesuades, firoflzes. and hazards
<br /> tlFdsts�n..h1 a sT2Aa . , - A8A-;1#4&v1 t < i t.�:.d =L�i�R 3L •'►l:it :1lil�rt..�t� $Rte."`` - -
<br /> ' _.+a a_M. ]IT�rT+r:7 j. i0 27il&9=OT fio"4� Yes E] No
<br /> answered -Yr-e to Chm4]8nr faE6*kV24 Do iro4-, f li tMllirsrdl ill ter `o a mixture containing a
<br /> ' hazardous material in a quantity equal to or greater than 55 gallons, 500 pounds. or 200 cubic feat at any one time?-
<br /> Yea- ❑,� lily ;:� �H� .�i,::.� :i rarer -xo*4=,; .9--03k AC 's. 4%
<br /> ' 04. Will the owner, applicant, or futures building occupant handle an Acutely Hazardous Material? (List of Acutely
<br /> Hazardous Materials xvarla!>k st:yta •ate 0 , pe>b iq Vj*"d
<br /> Yes ❑ Nor � ;znweieM aj -am&.1i x4e=A a-.sri
<br /> ' 05. Mi 'proposed bufld1bV'6r rte f it l�'IAIt 1 ,t3' 'F t�f'r't�t school (irides K-1;
<br /> ' Yes Q ALi
<br /> s Na*
<br /> I have read the Haz-,AWAIt �s Guide (b!*,blar.Jcpme 01 ,11 is under Chapter
<br /> S 95 of the Cott Sections 25505, 254111� and urtdersiarrd that If ft bwWnng do
<br /> ' not currentfy have a . - -�,qq respon dity to nodly the occupant of aha regL roffonts which must be mor
<br /> pear to issuance of rt p i declare Inreda+r;la~f4r Oy�daclosw* saxvey is
<br /> trio and accurate tavtht i+irl- al MY &no bE mal¢ tQ 0#-P '9 R� Calrforri
<br /> 5
<br /> irzt . u": ree,a -• •`':,l+L*••t c+.rttt rr berjjx rlw* 10
<br /> Owner or Authorl ed �elc�Ii�et. "�w
<br /> -- — (Prim} sal L17 UG,p1 *l,.Yn� vn0111 e 1t3 s,:a S3u�� r
<br /> ' _ (sugtuturel• ' 1 '� a `ate+ �e �` � `�
<br /> 1• sea Joaquin valley Waited Aur Few"Ge Cenril.aei.a 1 2K t 081ses atd1ingrs" 11mvieee t
<br /> Horth Region offlee Has"aws Notarlas omosen
<br /> ' 4230 Klarnan Ara., suite 130 222 L W~ Ave, 0eurtheus&.4oam $10
<br /> Modesto, CA 9s3" (7091 546-70040 Stockton, CA IS= (201) 44&3"9
<br /> 24-Hour Telephone: 1400.261.700a
<br /> Fu. (209)-345.4532 C[! Wap_ DATR !!_
<br /> AI*ROv! RLMCT _ V9MFWV _
<br /> HYYi�, 1tlMff SXIM" _ YS12M
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