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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES „z IN' <br /> ROOM 610,COURTHOUSE F *F <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 ��p SAN JOAQUIN COWQQ, <br /> HAZARDOUS MATERIALS DISCLOSURE SURVET''CEOFEMERGENCY SERVICES <br /> Please read the information on the reverse side before completing this survey form. A separate survey foreachbusiness name <br /> and/or address in San Joaquin County is required. <br /> CL <br /> Business Name: �o}>/LL�C) <br /> Business Owner(s)Nam//e: ?#r r'AtV- \G'r-/� '{ ,, Telephone: 0k%"0%%-(635XBusiness Address: to 1 �?�7\ C 14A44—`VTW'` k)A6 -l <br /> Mailing Address(if different from above): <br /> Nature of Business: �f�51 !k tJ�_� iS� Fire District: �'rbL��I <br /> Q 1. Dyes )2No 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. Dyes ,oto 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 /> 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 /> ❑ 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. Dyes 40 Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. Dyes >CNo 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. <br /> Owner or Authorized Agent: <br /> X ^Iy4`(y, Date <br /> Pr <br /> x Title AMA Cdh�sTltV�10.J N1N`�ACal1t <br /> Sign e eFlelA'S (Rev 10/96) <br /> ~ 7 3 <br />