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�qP�. <br /> r•.. Z <br /> SAN JOAQUIN COUNTY PIanRinglBldg C7ep , <br /> OFFICE OF EMERGENCY SERVICES <br /> �. ; HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> PLEASE PRINT OR TYPE <br /> Q1. Please provide a separate survey for business name and/or address in San Joaquin County: <br /> a. Business Name: ev f/t/►PS <br /> b. Business Owner(s) Name: 11 ry�7 f Phone: <br /> C. Facility Address: 2 O 1 5 CD a cQr� <br /> d. Mailing Address: ct l 0a <br /> e. Nature of Business: ayI ry Fire District: /—;/IM 11-7r <br /> f. Business Lic. No: /`�C��P Expires (Mo/Yr) Standard Indstrl Code NO: <br /> g. Proposed. Project: <br /> Q2. Does your business handle a hazardous material? "Hazardous Materlal" means any material that, because <br /> of its quantity, concentration, or physical or chemical characteristics, poses a significant present or potential hazard <br /> to human health and safety or to the environment if released into the workplace or the environment. (Includes fuels, <br /> petroleum products, paints, propane, oxygen, ammonia (EHS), chlorine (EHS), pesticides, fertilizers, and hazardous <br /> wastes...). <br /> Yes No 'LLI <br /> 03. If you answered 'YES' to Question 2 above: Do you handle a hazardous material or a mixture containing'a <br /> hazardous material in a quantity equWItor greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time? <br /> Yes ❑ No <br /> Q 4. Will the owner, applicant, or future building occupant handle an Acutely Hazardous Material? (List of Acutely <br /> Hazardous Materials available at the PI Department). <br /> Yes ❑ No <br /> Q5. Will proposed building or modifi facility be within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> Yes No <br /> I have read the Hazardous Materials Information Guide (on back page) and understand my require- <br /> ments under Chapter 6.95 of the California Health and Safety Code Sections <br /> 5505, 2rrty3 , and <br /> sl- <br /> 25534. 1 understand that If the building does not currently have a tenant, <br /> that it billty to notify the occupant of the requirements which must be met prior to Issuance of a <br /> Certificate of Occupancy. <br /> Owner or Authorized Agent: <br /> Title <br /> (Print) / �9 <br /> % Date I��� / � • <br /> (Signature) <br /> 2, Office of Emergency services <br /> 1, Sen Joaquin Alt Pollution Control District Hazardous Materials Division <br /> 2321 W. Washington St., suite 1 222 E. Weber Ave., Courthouse-Rm 610 <br /> Stockton, CA 95203 (209) 468-3470 Stockton, CA 95202 (209) 468.3969 <br /> OES INSP ____ DATE APPROVE REJECT REJECT VERIFIED _ <br /> ' HM1611p — RAAPP — EXEMPT_ <br /> V.3.0192 <br />