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City Bldg Dept L-U q( <br /> i `e application# <br /> COUNTY OFSAN JOAQUIN RONALD L BALDWIN <br /> `r'lV qU 1 <br /> COORDINATOR <br /> OFFICE <br /> OFFICE OF EMERGENCY SERVICES <br /> .G ROOM 610,COURTHOUSE RECEIVED <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 I�A 2007TELEPHONE(209)468-3962 <br /> • C,.. r�P HAZARDOUS MATERIALS DIVISION(209)468-3969 bAN JUHUUIN UUUN IY <br /> OFFICE OF EMERGENCY SERVICES <br /> HAZARDOUS MATERIALS SURVEY FORM <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each <br /> business name and/or address in San Joaquin County is required. <br /> Business Name: &i , Jc 1 -Cou <br /> Business Owner(s)Name: (Zi �r�Gt�(��,rc�� N� .906�c,V Zt LS Telephone: <br /> Business Address: 2mw. pipe sAe-4--44, UOU CW 6wmaft gsaLip <br /> Mailing Address (if different from above): N\P-- <br /> Nature of Business: Ci;+y Ga��M� Fire District: <br /> Ql. Yes ❑No Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br /> //////""""""TTTTTT of hazardous material on the back of this form. If your answer is"No,"go to Question 4. <br /> Q2. XYes ❑No Does your business handle a hazardous material,or a mixture containing a hazardous material,in a quantity <br /> equal to or greater than 55 gallons,500 pounds,or 200 cubic feet at any one time in the year? <br /> 0eJBr Ck-+ lococfa=In <br /> If"Yes," how long have you handled these materials at your business: 1'11-rode I W; <br /> WV kJ,o.S at o�hec Iot,4x s <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. ❑Yes %No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. XYes ❑No Is your business within 1,000 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 �S l�ken+'\ Date <br /> Print Name p� <br /> X Date <br /> Signature <br />