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� � .� ��ECE►VELA <br /> 20 <br /> bAl'JU <br /> �6� oPn®e��Q eo COUNTY OF SAN JOAQULN C�CEOFEMER NCYQN�iY <br /> r. <br /> = OFFICE OF EMERGENCY SERVICES RONALI &1DWVU1R10E$ <br /> m < ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> x STOCKTON,CALIFORNIA 95202 <br /> o�Y%cSR„ve , <br /> 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 Joa'gAmUn. C,,ounntty is required. <br /> w <br /> Business Name: ' _ ` 0N xt—ON-S Q.�tT�4tJ�t� <br /> Business Owner(s)Name: �tkW N ARl l US A Telephone: Q i h S g%A 3S7- <br /> y <br /> Business Address: OZ-6 L'oWrol— <br /> Mailing Address(if different from above): <br /> Nature of Business: �ytC ILS��-� �� ��1�4t/ ►1 Fire District: <br /> Q 1. Dyes �Ao 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. Oyes c?<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 /> ❑ 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 /> J C. This business operates a farm for purposes of cultivating the soil,raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. Dyes Vic, Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. Dyes rF�dv 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 A--"r.4 .- pl y Date 311L (0% <br /> Print Name <br /> X t"� Title h4'4N�- -F46*imA <br /> Signature (Rev 10/96) <br />