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D SAN JOAQUIN COUNTY DES USE OAI <br /> OFFICE OF EMERGENCY SERVICES <br /> t 15 AZARDOUS MATERIALS DISCLOSURE SURVEY <br /> P <br /> gpfFlce eparate survey for each business name and address in San Joaquin County: <br /> \� cr c- > �doy� q / -Q7SSS <br /> a. Business Name: �-.>�+ � ��- �-�r Phone: <br /> b. Mailing Address: cA2a Sca <br /> cry 95ao-s <br /> c. Facility Address: <br /> �P,r. �.� <br /> d. Contact Name: Phone: <br /> e. Nature of Business: n Q� <br /> 02. Does your business handle, store or transport a hazardous material? "Hazardous material" <br /> means any material that, because of its quantity, concentration, or physical or chemical <br /> characteristics, poses a significant present or potential hazard to human health and safety or to <br /> the environment if released into the workplace or the environment. (Includes gasoline, oil, <br /> propane, oxygen, acetylene, ammonia, chlorine, pesticides....) <br /> Yes Q No <br /> Q3. If you answered "YES" to Question 2 above: Do you handle, store or transport a hazardous <br /> material or a mixture containing a hazardous material in a quantity equal to or greater than 55 <br /> gallons, 500 pounds, or 200 cubic feet at any one time? <br /> Yes No <br /> If you answered /"YES" to Question 3 above: Chapter 6.95 of the California Health and <br /> Safety Code requires businesses which handle hazardous materials, at the California Threshold <br /> Planning Quantities, to file a "Hazardous Materials Management Plan (HMMP)" with the <br /> Administering Agency. In San Joaquin County, the Office of Emergency Services has been <br /> appointed to be the Local Administering Agency. Businesses that handle Extremely Hazardous <br /> Substances will also be required to file an Extremely Hazardous Substance (EHS) <br /> Registration Form and possibly complete a Risk Management and Prevention Program <br /> (RMPP). <br /> Should you have any questions, please call the Office of Emergency Services at (209) 468-3969. <br /> Owner or Authorized Agent: <br /> (Print) Title <br /> (Signature) Date <br /> Please return this survey form to: <br /> Office of Emergency Services (Office Use Only) <br /> Hazardous Materials Division Date Received: <br /> 222 E. Weber Avenue Inspector/Clerk: <br /> Courthouse-Room 610 Date Verified: <br /> Stockton, CA 95202 EXEMPT/HMMP: <br /> HMMP Due Date: <br /> OES/DA/FD/ENV/APCD: <br /> v <br />