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IL OCT 51999 <br /> COUNTY OF SAN JOAQUIN <br /> - <br /> °� a coo - <br /> OFFICE OF EMERGENCY SERVICES 9t0NAL0_WI9btpW^ IN <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> �.. STOCKTON,CALIFORNIA 95202 <br /> �ticoa`'� TELEPHONE(209)468-3962 <br /> 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: c <br /> Business Owners)Name: L.- _ —_ - --Telephhoottei &K JS 7-z-7-27� <br /> Business Address: 7d � <br /> Mailing Address(if different from above): s�3 <br /> Nature of Business: C�dJva4-0r� /SC+�Iti/ r�eef+ y�i Fire District: s( j_ <br /> Q 1. &Yes .-]No Does your business handle a hazardou��dterial t(any quantic rf onetime n�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. ❑Yes PIo 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_Q&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. F-lYes gNo Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. DYes Wo 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: / / /// /D �j�j <br /> X L.]e.�t /S. Z.TriltYlc" Date <br /> / P ' t / <br /> X ru [_ (�� Title !w S�fr <br /> 6ignature - (Rev 10/96) <br />