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.pis S <br /> R4 'y �� COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RECEIVED <br /> < Room 610, Courthouse <br /> 222 East Weber Avenue OCT 2 32006 <br /> Stockton, California 95202 SAN JOAQUIN COUNTY <br /> �qC/FO•M1a`P <br /> Telephone (209)468-3962 OFFICE OF EMERGENCY SERVICES <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 <br /> name and/or address ii�n\lSan <br /> ,Joaquin County is required. <br /> Business Name: 1 �\y/L�n CAX) l►X�-�(N/ `���t/�✓ ^J I�f \ <br /> Business Owner(s)Name: DlinD X1"1 Ly IC UV1 1 I (�/�, (T'�elepho/n'e: v/] J ^y?'-1 Li <br /> Business Address: 1 J-1 -31 1"�Dv AiI ki�ci I WU�^ v-fV'� t�U0(A <br /> � ` 1 Z� D <br /> Mailing Address(if different from above): (/` bV2- N�V 1L"" \ 1"l/ � � ` <br /> Nature of Business: Vv�NQi/l� Fire District: <br /> Q1. OYes IfkNo 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. OYes XiNo 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 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 /> OA. The hazardous materials handled by this business is contained solely in a consumer product, <br /> packaged for direct distribution to, and use by, the general public. <br /> OB. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. <br /> OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes A1No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes'No Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code. I understand that if I own a facility or property that is used by tenants, that it is my responsibility to notify the <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I <br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best <br /> of my knowledge. <br /> Owner or Authorized <br /> /Agent: <br /> X r q �G ✓l 1 Date: \ O I�L I u� <br /> Pri uV`7V / lVl Ce,y�✓ia7Gt�cl) <br /> X ., +• Title: <br /> Signatur <br /> F:\DevSvc\Planning Application Forms\Business License(Revised 08-30-06) Page 4 of 7 <br />