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A4,N COUNTY OF SAN JOAQUIN RE "M <br /> aaQ ?� OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE �1WII,., tT• STOCKTON,CALIFORNIA 95202 ME <br /> {tiYo'ai� TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS SURVEY FORM <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 r fired. <br /> Business Name: 6 4t,Business Owner(s)Name: L` Telephone: C�-v'') 7Z))776 <br /> Business Address: I ZY ZQ Z—d c C C z 3 <br /> Mailing Address(if different from above): <br /> r, <br /> Nature of Business: J' Fire District: <br /> Ql. Yes ❑No Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> /Yes <br /> of hazardous material on the back of this form. If your answer is"No", go to Question 4. <br /> Q2. y�x 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? I <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 Qply medical gases. <br /> ❑ C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> J/ agricultural or horticultural commodity. <br /> Q3. ❑Yes 2d 0 Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes C�Io 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 Ant: <br /> / C <br /> X � d �� ( Date <br /> rin Na e <br /> X— Title �l�lJLC� <br /> ature (Rev 10/96) <br /> a <br />