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�fi •.o <br /> r % COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMEP.GENCY SERVICES <br /> < Resor 016 CDuwnqut[ " RONALD IL 9ALDWIN <br /> 222 EAST WEBER AVENUE <br /> •:q.ri �P• SrOCKTON, CALIFORNIA 96202 <br /> L i a G p N Tn t(2091 Aga-39412 <br /> NAIAR L0 MATOII OMMMN(2091 "&3969 <br /> e KIFT70N VEROMM&APPROVED <br /> EXEMPTION STATEMENT 'T DATE <br /> APPROVED Rrrecr_ <br /> I understand the requirements of Chapter 6.95, Division 20, Section 25500 et seq. of the California <br /> Health and Safety Code which pertains to emergency planning by businesses using hazardous materials. <br /> My business claims the following exemption(s) from the Hazardous Materials Management Plan require- <br /> ments: <br /> It does not handle a hazardous material,or a mixture containing a hazardous material,in a quantity equal to or greater <br /> than 55 gailons.500 pounds,or 200 cubic feet at standard temperature and pressure for compressed gas at any one time <br /> or an acutely hazardous material in quantities greater than the associated threshold planning quantity. <br /> The hazardous material handled by this business is contained solely in a consumer product packaged for dicot dis- <br /> tribution to,and use by,the general public(Le. retail). <br /> This business operates a farm for purposes of cultivating the soil or raising or harvesting an agricultural or hard- <br /> cultural commodity. (Checking this box will put.your business in the Farm Inventory Program). <br /> This business operates a health care facility and uses only medical gases(Le. docror, dentist, vererinar.v..). <br /> Q Other (Describe in detail for review by administering agency). <br /> NameofBusiness OwIrNy\ <br /> Nature of Business�fa�,rb���rn <br /> Nlail_ingAddrees(ss— q< IA.VI�t!"Vt/"'D 6 • �� <br /> UIPhone(/m )�j �j��(I�� u� VV <br /> City VUJl1i" ' Zip Code V ✓! � <br /> Facility Address Ah Phone( A" )(� <br /> City n , Zip Code ` ✓ <br /> Nearest intersection of facility site NMYlll V / �_A i1 Fire District <br /> 1 declare under enaky of perjury Hutt this statement is true and accurate to the best of my knowledge and is made in the <br /> City of ��.I��C�Yl .California. <br /> Owner/blanager DAVto lb, pl et'AN t : _Title nwAiv <br /> Print Namc 'n <br /> Signature D2kµ4li� Date t� D <br /> signamr:in Ink big= <br />