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osQ�tN. COUNTY OF SAN JOAQUIN <br /> r.- <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> m `=i ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> • c•.. STOCKTON,CALIFORNIA 95202 <br /> TELEPHONE(209)468-3962 ( Q �j G '7 �yy� ! <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 DRi. 1 S9 <br /> HAZARDOUS MATERIALS SURVEY FORM f <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: S I e«c`- C)e"�n`CCG( <br /> Business Owner(s)Name: S- ti(P 7 I<,11 W e,- Telephone: r-7 7s) <br /> Business Address: 3 r <br /> Mailing Address(if different from above): <br /> Nature of Business: C"("•P."tt I 0 ccj Fire District: S��C� dil <br /> Ql. Yes ONO 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. es []No 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 /> J 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. XYes ONO Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes 'ENO 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 <br /> LC/�/1f,� KF I �c f Date 7 Z3 i <br /> / t Name Title 7/2 7�1 / <br /> 7{ v<<- /d - I - — <br /> Signature (Rev 10/96) <br />