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• Planning/Bldg. Dept. <br /> File Na. l & - 3/77 <br /> Q N COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> r a ROOM 610,COURTHOUSE COORDBJATOR <br /> N: [ <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 —/l(��1aI(/J' <br /> LC P. <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS SURVEY FORM <br /> Please read the Hazardous Materials Information Guide on the back side before completing this survey form. A separate form for <br /> each business name and/or address in San Joaquin County is required: <br /> Business Name: Ac—n— 9/0 4)250r- <br /> Business <br /> )250rBusiness Owner(s) Name:e-B,Vp¢Ldlfln Phone: 209 1.9r —$;1/ ' <br /> Facility Address: :36?B3 S L--L /?OC�i2D� SST/ q ��' <br /> Mailing Address: 3 If9-3 .:2: 9�E/ Aj2A,"O �Y / // <br /> Nature of Business: LUne»�[,Z_ "A/R— Fire District: S-� n/ <br /> Ql. Yes ❑ No Does your business handle a hazardous material? Read back nage. If you answered"No"to Question 1, <br /> go to Question 4. <br /> Q2. Yes ❑ No 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? <br /> If you answered "No"to Question 2,go to Question 4. <br /> If you answered"Yes"to Question 2,do any of the following statements apply to your business?Read <br /> back Daae. <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 operates a health care facility (i.e.,doctor, dentist, veterinary...) and uses only medical <br /> 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. ❑ Yes X No This business or building occupant handles an Acutely Hazardous Material?Read back Dage. <br /> Q4. ❑ Yes No This facility or modified facility will be within 1,000 feet of the outer boundary of a school (grades <br /> K-12). <br /> I have read the Hazardous Materials Information Guide and understand my requirements under Chapter 6.95 of the California Health <br /> and Safety Code. I understand that if the building does not currently have a tenant, that it is my responsibility to notify the <br /> occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. I declare under the penalty of <br /> perjury that this disclosure survey/exemption is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> X Title / . s alit <br /> Print <br /> SAN JM019N^Cn, l/ - /�� <br /> X ^,)� R I R n e t_ 910 OFFICE OF Date 7 <br /> Signature <br /> Rev:1/96 <br />