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RECEIVED <br /> FEB2 0 2M8 <br /> SAN Auu N couN1Y <br /> r V i r a OFFICE OF EMERGENCY SERVICES <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <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 Joaquin County is requir . t /A.Ri i4 <br /> Business Name: <br /> Business Owners)Name: I�(I Telephone: N F 1J�3• <br /> l 2 0(o <br /> Business Address: <br /> Mailing Address(if diff ent from above): ( '\. H <br /> Nature of Business:� 4 wt I C' Fire District: <br /> Q1. AYes lk1 No Does your business handle a hazardous material in any quantity at anyone time in the year. Seethe <br /> definition of hazardous material on the back of this form. If your answer is"No,"go to Question 4. <br /> Q2. Yes O No Does your business handle a hazardous material,or a mixture containing a hazardous material in a quantity <br /> equal to or greater than 55 gallons,500 pounds,or 200c 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 apply to your business. <br /> OA. 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 /> OB. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses only medical gases. <br /> OC. This business operates a fans for purposes of cultivating the soil,raising,or harvesting an agricultural or <br /> horticultural commodity. <br /> y� <br /> Q3. OYes ypNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes ONo 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 the <br /> 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 jrjAthonzed Agent: <br /> X 0 Date: Z, ( ( O <br /> X t eC( Mlfll� <br /> Title: <br /> Signature <br />