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6'' QS <br /> S <br /> >° 4--.E COUNTY OF SAN J0,-4UIN RECEIVED <br /> YFFICE OF EMERGENCY SERVICES <br /> �� 2101 E. Earhart Avenue, Suite 300 JAN 18 2011 <br /> Stockton, California 95206 <br /> Telephone (209)953-6200 SAN JOAQUIN COUNTY <br /> N FAX (209)953-6268 OFFICE OF EMERGENCY SERVICES <br /> r— <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 Name: :7WI nL5 QUO —k;lcpq, 0- <br /> Business Owner(s) Name: � �s i�ii� /D Telephone: 2-e V <br /> Business Address: IS2S7 �i.JY `��/ hJcri9t�(Q r � %SSSG <br /> Mailing Address (if different from above): <br /> Nature of Business: &-/a C? j> Fire District: <br /> Q1. RlYeS ❑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. 6Yes ❑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 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 /> EfA. 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 /> ❑B. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3. E6Yes ❑No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. &Yes ❑No 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 /> X 5 S '214/6) Date:C/ /07—,2 D <br /> Print Name <br /> X Title:1n�/7a <br /> Signature <br /> F:\DevSvc\Planning Application PomMBusiness License(Revised 01-2510) Page 4 of 7 <br />