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COUNTY OF SAN Jt,nQUIN RECEIVED <br /> ). / AG <br /> r' z OFFICE OF EMERGENCY SERVICES <br /> '` Room 610, Courthouse FEB -5 <br /> 2009 <br /> 222 East Weber Avenue <br /> rq ..••,• ..•:4' � /�� ' Stockton, California 95202 SAN JOAQUIN COUNTY <br /> Telephone (209)468-3962 OFFICE OF EMERGENCY SERVICES <br /> 1 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 name <br /> and/or address in San Joaquin County is required. <br /> Business Name: e ✓i9T�D�✓ <br /> Business Owner(s) Name: Telephone: <br /> Business Address: <br /> Mailing Address (if different from above): <br /> Nature of Business: e-.7w/G Fire District: <br /> Q1. OYes ❑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. "§fYes ❑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 200cubic feet at any one time in the year? <br /> If"Yes," how long have you handled these materials at your business? 2 U y e =:> <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> CdA. 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 /> ❑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 agricultural or <br /> horticultural commodity. <br /> Q3. ❑Yes VVo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes W,;ro 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 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. 1 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 Date: <br /> X 1�f' me <br /> x Title: 67e-1/l <br /> Signature <br /> F TevSvcB°lanning Application Forms\Business License(Revised 05-01-08) Page 4 of 7 <br />