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y < <br /> CIFORN <br /> V� COUNTY OF SAN JOAQUIN RECEIVED <br /> OFFICE OF EMERGENCY SERVICES DEC 1 :% M? <br /> Room 610, Courthouse SAN JOAUUIN CouNI Y <br /> 222 East Weber Avenue OFFICE OF EWRGENCY SEROCEE <br /> Stockton, California 95202 <br /> 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 is required. <br /> Business Name: 40C","46 n as4r rn// c <br /> � / <br /> Business Owner(s) Name: 7—lc. CrlO"C)&� Telephoneb-05 C)o <br /> Business Address: /Fr <br /> Mailing Address (if different from above): <br /> Nature of Business: 11 � Fire District: <br /> Q1. gYes D No 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. OYesNo Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br /> 91equal 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 /> OA. 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 /> OB. This business is a health care facility(doctor, dentist, veterinary, etc.) and uses ooh 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 DNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes *q 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 4&nit c G c Date: !E/14L6- 1"e7 <br /> Printre <br /> X ,7 Title: <br /> Signature <br /> F'BURDINGW NO ERMITAW-WMMERCI&D FYee105(Revle l� 3LLW) Page 4 of 5 <br />