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r <br /> Z' s RECEIVED <br /> of n <br /> MAY ` y ?"to-'COUNTY OF SAN JOAQUIN E"-!gXWxtrNCaa�Y.rTY <br /> OFFICE OF EMERGENCY SERVICESFRCEU' .IiiEkGM ` SERWA <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 <br /> name and/or address in San Joaquin County is required. <br /> Business Name: L—oc)\ -M.__,(tZ:_,(�L1TF.iE <br /> Business Owner(s) Name: E-2tC_ A p Eat- Telephone: A,cI -�"(r j. 1431 <br /> Business Address: ('lie$) I 11Q,0L'2v3t1 Sci4 'ti1Y.0 <br /> Mailing Address (if different from above): <br /> Nature of Business: IV-`3 4 "DA,L-ES Fire District: w' 7Ur�r3R_Ip( <br /> Q1. Ye)s IhNo Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on the back of this form. If your answer is <br /> No,"go to Question 4. <br /> Q2. Y s 1ANo Does your business handle a hazardous material, or a mixture containing a hazardous <br /> material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at <br /> 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 /> OA. The hazardous materials handled by this business is contained solely in a consumer product, <br /> packaged 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 onl'q medical gases. <br /> OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes 0o Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. OYes PNo 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 <br /> Safety Code. I understand that if I own a facility or property that is used by tenants,that it is my responsibility to notify the <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I <br /> declare under the penalty of perjury that the Information provided on this disclosure survey is true and accurate to the best of <br /> my knowledge. <br /> Owner or Authorized Agent: <br /> X2l .4. K�E'�-4- Date: r"!"�i -7Z03 <br /> Prin Name(ZE-S. <br /> X Title: <br /> Signat e <br />