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Dept. <br /> SAN JOAQUIN COUNTY L-#: <br /> OFFICE OF EMERGENCY SERVICES <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> PLEASE PRINT OR TYPE <br /> Q1. Please provide a separate survey for each business name and address in San Joaquin <br /> County: <br /> a. Business Name: Tierra Resources Inc. Phone: (209)931-1847 <br /> b. Mailing Address: 10199 Fust Waterloo Road <br /> Stockton, CA 95205 <br /> c. Facility Address: 26255 Brandt Road <br /> Lodi, CA 95240 <br /> d. Contact Name: Edward ouesto Phone: (209)931-1847 <br /> e. Nature of Business: aggregates <br /> f. Proposed Project: sand and gravel, and placer gold <br /> Q2. Will the owner, applicant or future building occupant handle a hazardous material? <br /> (Includes gasoline, oil, propane, oxygen, acetylene, ammonia, chlorine, pesticides. . . . ) <br /> ® Yes = No <br /> Q3. Will the owner, applicant or future building occupant handle an Acutely Hazardous Material? <br /> (List of Acutely Hazardous Materials available at the Planning Department) <br /> = Yes Q No <br /> Q4. Will the proposed building or modified facility be within 1,000 feet of the outer boundary of <br /> a school (grades K - 12)? <br /> Yes I No <br /> I have read the Hazardous Materials Information Guide (on back page) and understand my <br /> requirements under Chapter 6.95 of the California Health and Safety Code Sections 25505, <br /> 25533, and 25534. I understand that if the building does not currently have a tenant, that it is <br /> my responsibility to notify the occupant of the requirements which must be met prior to issu- <br /> ance of a Certificate of Occupancy. <br /> Owner or Authorized Agent: (Print) _ <br /> Date: August 24, 1990 (Signature) // ,g o —_Z?�' <br /> (Office Use Only) <br /> 1 . Son Joaquin Air Pollution Control District <br /> 1601 East Hazelton Street <br /> Stockton, CA 95205 <br /> (209)468-3470 <br /> 2. San Joaquin County DES <br /> 222 East Weber Avenue, <br /> Room 6100 <br /> Stockton, CA 95202 <br /> (209)468-3969 1 .9 <br />