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p4u•" COUNTY OF SAN J%wAQU1N <br /> >.°•fit•boa �-- <br /> �' "— OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber AvenueStockton, California 95202 RECEIVED <br /> ...�di lFoaN P <br /> Telephone(209)468-3962 <br /> Hazardous Materials Division (209)468-3969 MAR - 2 2009 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY SAN JOAQUIN COUNTY <br /> OFFIE OF EN <br /> �ERGENCY SERVICES <br /> Please read the information on the reverse side before completing this survey form. A separate survey or eac business name <br /> and/or address in San Joaquin County is required. <br /> Business Name: ACCuk.,ATE -6z—AA6mie6 (at4b <br /> Business Owner(s) Name: C fEK l S/Ti n/rA n�4Z•Pn,JFl o Telephone:/+ <br /> Business Address: f�t) /11t - 45 <br /> Mailing Address (if different from above): '702I k). 5-nCk'� J CA <br /> I ' <br /> Nature of Business: �2AN6rnl�hroA) �MeeTSr �JALES ��J 1/IICFFireDistrict: ;:�"6lID <br /> Q1. bYes ❑No Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br /> of hazardous material on the back of this form. If your answer is No," go to Question 4. <br /> Q2. []Yes MINo Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br /> equal to or s qrealer than 55 gallons, 500 pounds, or 200cubic 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 <br /> for 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 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 ialNo 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 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: <br /> X d4tef5TiN4 ( RA�1F;UL, Date:--0-1 Oq <br /> Print Nape l <br /> X (rliLLw .r_e_ 7 :.+amu [ Title: �e h/ <br /> Signature <br /> F\DevSvc\Planning Application Foons\Business License(Revised 01-18-08) Page 4 of 8 <br />