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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES CFS <br /> e 2101 E. Earhart Avenue, Suite 300 <br /> Stockton, California 95206 <br /> •.:fir•• Telephone(209)953-6200 MAY 2 4 ?010 <br /> ' 0 FAX(209)953-6268 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY ��G� 411Q oQuH'OgkC <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business n <br /> and/or address in San Joaquin County is required..I1 <br /> Business Name: P177/a �t—(veF� <br /> Business Owner(s)Name: ii�� DwI i.� UW( Telephone: , A ( gam <br /> Business Address: I bcdi 6 E fl q �s C6 �I0l)ld 0 lk;; <br /> Mailing Address(if different from above): ?0 b OX 1,1 O Zj_D^ — C4 _l�ID '1 b <br /> Nature of Business: �12�7�" Fire District: <br /> Q1. OYes b(No Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br /> of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> 02. DYes ONo 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 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, packaged <br /> 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 agricultural or <br /> horticultural commodity. <br /> Q3. OYes llo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes 00 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 5.95 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_ r Dater/! <br /> X Title: �r /\-� <br /> gnature <br /> F:�SvclPlannft Application FormMBusiness License(Revised 01-25-10) Page 4 of 7 <br />