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• • <br /> COUNTY OF SAN JOAQUIN <br /> �•'�a,o <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> 8�.,. STOCKTON,CALIFORNIA 95202 <br /> /FOp~ <br /> TELEPHONE(209)468-3962 SEP I 5 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 L <br /> 20 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEYJ <br /> S;N JC107!1,1 f^lltJ?Y <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: uAS 101 S DI-to 11;U#k a^1 Q h�4��S�Abffie! <br /> Business Owner(s)Name: �%/J `�,S ��14 Ti o-�i�, C ' Telephone: (Sb3h91' J OC)i <br /> Business Address: 3$10 4#AXN cA- $Toa-To.,J , r+E 1750111 <br /> Mailing Address(if different from above): <br /> Nature of Business: F•�� ���T Fire District: 5'(O(�C7 0r1 <br /> Ql. VYes ONO Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> JJ definition of hazardous material on the back of this form. If your answer is"No",go to Question 4. <br /> Q2. ❑Yes SIND 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 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 /> ❑ 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 /> ff agricultural or horticultural commodity. <br /> Q3. [-]Yes4No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes 4No 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 <br /> the 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 1m- J Date —It <br /> '1�1� <br /> X Title <br /> ignature f (Re <br />