Laserfiche WebLink
5.j. c <br /> Punning/Bldg. Oept. <br /> ._,e No. <br /> COUNTY OF SAN JOAQUIN <br /> ,o .coG OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> H { ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> �4 STOCKTON,CALIFORNIA 95202 <br /> A TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS SURVEY FORM <br /> completing Please read the Hazardous Materials Information Guide on the back side before p leting b this survey form. A separate form for <br /> each business name and/or address in San Joaquin County is required:or <br /> Business Name: 1 — a ft6r <br /> Business Owner(s) Name: G A�,V a L1 t,)A)Fi Q-6CL Phone: 3 L-, <br /> Facility Address: 41415 C Q L-L 6 LJ A\1 CT'' <br /> Mailing Address: <br /> Nature of Business: M F,�)i R rb L A5 i I f3 G Fire District: I la <br /> Q1. ❑ Yes C9.No Does your business handle a hazardous material? Read back page. If you answered"No"to Question 1, <br /> go to Question 4. <br /> Q2. ❑ Yes ❑ 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 200 cubic feet at any one time? <br /> If you answered"No" to Question 2, go to Question 4. <br /> If you answered"Yes"to Question 2,do any of the following statements apply to your business?Read <br /> back page. <br /> ❑ A. The hazardous materials handled by this business is contained solely in a consumer product packaged for <br /> direct distribution to,and use by,the general public. <br /> ❑ B. This business operates a health care facility (i.e., doctor, dentist, veterinary...) and uses only medical <br /> gases. <br /> ❑ C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑ Yes ❑ No This business or building occupant handles an Acutely Hazardous Material?Read back page. <br /> Q4. ❑ Yes ❑ No This facility or modified facility will be within 1,000 feet of the outer boundary of a school (grades <br /> K-12). <br /> I have read the Hazardous Materials Information Guide and understand my requirements under Chapter 6.95 of the California Health <br /> and Safety Code. I understand that if the building does not currently have a tenant, that it is my responsibility to notify the <br /> occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. I declare under the penalty of <br /> perjury that this disclosure survey/exemption is true and accurate to the best of my knowledge. <br /> t� <br /> Owner or Authorized Agent: R % L' t <br /> X h-����} C*,_ Title <br /> Print <br /> X -� Date <br /> Signature so JONERRio SIR\IICtES <br /> Rev:1/96 <br />