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oAq,,,y RECEIVED COUNTY OF SAN JOAQUIN <br /> AUG 18 2009 OFFICE OF EMERGENCY SERVICESa� <br /> m < 2101 E. Earhart Avenue, Suite 300 <br /> SAN JOAQUIN COUNTY Stockton, California 95206x5 Y� <br /> •'�' :° '�1 I1FRtEOFEMERGENCYSERVICES Telephone (209)953-6200 -5,,, w, <br /> d<iFOR�' FAX (209)953-6268 �� S� p_r <br /> ( ` HAZARDOUS MATERIALS DISCLOSURE SURVEY -� \4p SC0_ _.rid_s <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: <br /> Business Owner(s)Name: 1 { Ten i- - ?v im Telephone,\Z!Pq q=,�Z5 <br /> Business Address: <br /> Mailing Address(if different from above) r�O I c�07 A� a �r%i C l�1 G yL°� <br /> Nature of Business: (�p�\p �o bnnuc c a:X _ Fire District: WOMA <br /> Q1. ❑Yes_(No 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. DYes ANo 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"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 /> CA. 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 /> CB. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. <br /> DC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> �( <br /> horticultural commodity. <br /> Q3. DYes XXNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. CYes I No Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> I have read f 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 Authoriz gent: <br /> X L _� v_dn� Date: <br /> Print Name �'7 <br /> X Title: ^� ro 5-, <br /> � <br /> Signature <br /> F:0evSvc\P1anning Application Forms\eusiness License(Revised 03-09-09) Page 4 of 7 <br />