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S C Nd <br /> ��- 020 0 S <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> • c �s• STOCKTON,CALIFORNIA 95202 <br /> sc%koR' TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business name <br /> and/or address in San Joaquin County <br /> \is required. <br /> Business Name: Quest <br /> Business Owner(s) Name: Telephone:.1 -5 q)—4�jq —-aA <br /> camem9e, d d�� Yt�vlr�e� ,�e � \��;�de 613 . o? ZOS <br /> i �i�wee Address: // <br /> Mailing Address(if different from above): Z s� �o�` 5 (��y Sja GK o , qP S ZOO �`+\ <br /> Nature of Business: �1S1�11 INK \Q�/eC .�\t)'CGN``C� `!1 �\ Fire District: <br /> Q L 2Ves ONO Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material on the back of this form. If your answer is"No",go to Question 4. <br /> Q2. [Kes ❑/N� o 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 in the year? <br /> t b .-( K J-e- If"Yes",how long have you handled these materials at your business? \ <br /> If "Yes",check any of the following conditions that applies to your business? <br /> �l{j 6 C 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 is a health care facility(doctor,dentist,veterinary,etc.)and uses only medical 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. 7_y es ]No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes �o Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? <br /> I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br /> Code. I understand that if I own a facility or property that is used by tenants,that it is my responsibility to notify the tenants of <br /> the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the �\ <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. 'l <br /> Owner or Authorized Agent: <br /> X 7kn)6-2i F6y1zf)iG Date .6F-6dr /I2r�DD <br /> Print Name <br /> X AAm21br, Title <br /> II II LL Signature �— (Rev 10196) <br /> k e of /c./ <br />