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• <br /> pe''Q�!.N•. C <br /> RECE -D <br /> PR �5 19 9 • �4GIFpRa`p• JUN ( 1 2018 <br /> COUNTY OF SAN JOAQUIN ENVIRONMENTAL HEALTH <br /> Environmental Health Department PERMIT/SERVICES <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> Telephone (209)468-3420 <br /> FAX(209)468-3433 <br /> Website: www.sjgov.org/ehd <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 is required. <br /> Business Name: 00tAp TE \N"0_6��y, 60� 1 <br /> Business Owner(s)Name: KI� rvWOLLOK.L Telephone: 09 . A4130RP <br /> Business Address: 0'401 N- ?*OKWAd &T0t"TVfJ1iCA `15205 <br /> Mailing Address(if different fro above): F.D. �x 9,5110 �/�Q ' &A p`f� <br /> Nature of Business:� vyi'ouh0 _Fire District: <br /> Q1. OYes ❑ No Does your business handle a hazardous material in any quantity at anyone time in the year. Seethe <br /> definition of hazardous material on the back of this form. If your answer is"No,"go to Question 4. <br /> Q2. 1 Yes O No Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br /> equal to or greater than 55 gallons, 500 pounds,or 200c any one time in the year? <br /> If"Yes,"how long have you handled these materials at your business? <br /> If"Yes,"check any of the following conditions that apply to your business. <br /> �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 /> OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3. �Yes ONo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes Ipo Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 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 the <br /> 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. <br /> Owner or Authorized Agent: j <br /> X & 1 Q / Date: 1201R <br /> Print Name (_O <br /> X Title: <br /> Signature <br /> F:1Application Forms&Handouts\Building Application Checklists\Check List Commercial Building Permit.doc(Revised 01/0812016) 3 of 4 <br />