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• • RECEIVED <br /> �o�aS!!N`• ov <br /> �6, COUNTY OF SAN JOAQUIN FEB 2 4 2011 <br /> OFFICE OF EMERGENCY SERVICES SAN JOAQUIN COUNTY <br /> 2101� E. Earhart Avenue, Suite 300\ OFFICE OF EMERGENCY SERVICES <br /> Stockton, California 95206 <br /> rtg2iFoa��P Telephone (209)953-6200 <br /> FAX(209)953-6268 <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 <br /> Business Name: ej,sfot 4- V 1 < L C—/ <br /> Business Owner(s) Name: / ( z ,fla 0 'j. &('c Telephone: 2-O 3 - -76 Z —YJ-00 <br /> Business Address: 2 5 Y rI Moy..�fa r#A L.k p�r�i -9 L�r'AC ` 64 9S3 -1 <br /> Mailing Address(if different from above): <br /> 1 Pe d I Q ALLX 3-90 W e! (f pl / CT 066 <br /> Nature of Business: 061efa/c dl5litw`ru1A r • Ccnf cr Fd' Fire District: Tracy &le <br /> rcn! ayj I <br /> Q1, VYes ONo Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br /> of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2. Xes ONo 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 200cubic feet at any one time in the year? <br /> If"Ye how/Ion nave t <br /> you han led th se mater I <br /> e s a yo business.?business? e�r/ <br /> P^C^^< tw �YT/ a �e�) ac.� jFCRTn(i to ov� <br /> If"Yes," check any of the following conditions that applies to your business. <br /> OA. The hazardous materials handled by this business is contained solely in a consumer product, packaged <br /> for 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 farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> CesW. W []No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> C,5'j�. <br /> Q4. OYes *o Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 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 /> X <br /> M1e4a.'/ c Date: <br /> /1 ri t Name n / <br /> X ( Title: L v<c v ��n ( ,r.,Signature <br /> FADevSvcTlanning Application Forms\Business License(Revised 01-2510) Page 4 of 7 <br />