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n. COUNTY OF SAN JOAQUIN <br /> g "'A OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> ROOM 610,COURTHOUSE COOK „ <br /> 222 EAST WEBER AVENUE <br /> • ,. STOCKTON, CALIFORNIA 95202 DEC 3 O 2003 <br /> r<� TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please rea the information on the reverse side before completing this survey form. A separate survey for each business name <br /> and/or add ess in San Joaquin County is required. L <br /> Business P arae: YP"e' U 1 -41- 455 -7 tp l/ <br /> Business wner(s)Name: / 'Arc- <br /> Mailing <br /> ✓� 12e� /-`� �hCV T/el�ephone'7g7d� <br /> Business ddress: -7 U / ,ArG �l f��� (�1 �-� ✓'3'/� ` 1� / s 33 b, ] p <br /> Mailing A dress(if different from above):r 7 <br /> �,.S <br /> Nature of usiuess:4rAft-97-f �Cf/r �-K �'-1lym<, Fire District: <br /> ��-e- J <br /> Q 1. _ es ONO Does your bu mess 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. Alyes ONO 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 aply 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. L Yes ONO Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. E Yes -No Is your business within 3,000 feet of the outer boundary of a school (grades K-12)? <br /> I have rea( the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br /> Code. 1 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 require ents which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty ofTurdurnzed <br /> Owner or Agent: <br /> I <br /> X lJ if Wl r Gt G/C $ (/Y) ate <br /> % Title Tu Kid( /r <br /> v SilVature <br /> (Rev 10)96) <br /> I <br /> S ' d 6SOS-13913 (602) T dor le <br /> 4 1 Jo F'4I0 WdbT = T 2002 11 Da0 <br />