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a�R"'IN• c <br /> COUNTY OF SAN JOAQUIN ��� 16 199$ <br /> �.• a'•.o <br /> .� OFFICE OF EMERGENCY SERVICES RONALD i~BALD <br /> r.• ,_ <br /> a ROOM 610,COURTHOUSE <br /> N: < OF <br /> 222 EAST WEBER AVENUE E ENCY <br /> • c���'�Roa���' STOCKTON, CALIFORNIA 95202 /6 <br /> 51 <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3 69 <br /> HAZARDOUS MATERIALS SURVEY FO <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 <br /> is)required. <br /> Business Name: e /P//10, <br /> Business Owner(s)Name: �/:h�/1�,�/��/— Telephone: 9 R — 0 Cl? J O <br /> t <br /> Business Address: L0 ag�i� 7�/a <br /> Mailing Address(if different from above): <br /> Nature of Business: ( fir i I . Fire District: <br /> Q1. ❑Ws []No 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. [' s ONO 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 /> agricultural or horticultural commodity. <br /> Q3. COYes ❑No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes [R<o--- <br /> 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 1 l l <br /> C /` Date <br /> Print Name <br /> XL n Title <br /> Signature ev 10/96) <br />