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,oP:nor-&.�oo <br /> RECEIVED <br /> MAP 13' 200f <br /> Cq CIFO R�'P <br /> TY <br /> OFFICE OF EMERGENCY SERRVICES, <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 required. n <br /> Business Name: A.7 /rl trh <br /> Business Owner(s)Name: j i 2A .J Telephone: r Z _0 <br /> Business Address: /3S Zr ,spa iii 1 S c� efq 9j�Z/� <br /> Mailing Address(if different from above): <br /> Nature of Business: ",c L Fire District: <br /> Q1. ❑Yes e''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. ❑Yes *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 /> 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 /> �S. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. <br /> This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3. []Yes Flo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. Wes Jlo 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 or Authorized Agent: <br /> XDate: <br /> nn e <br /> ue: <br /> Signature <br /> F'.BUILDINGVONWO ERMITAP -COMMERCIAL.DOC Nee125(Revim 143P02) Page 4 of 5 <br />