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1 nA!!!,ry <br />n, O. C <br />2:' <br />f: 2.1 <br />N: X <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 />RECEI!/E,,C) <br />FEB 2 7 20n3 <br />S.^NJOp(1pIh%0V0k Y <br />FfrCEGrCih�PtGEN" y ShR,4CF <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: _ N UI ID t IA'T-U11 c-�C.r V i C.� a <br />Business Owner(s) Name: Wni I( 1. A ' /}fah n � - Telephone: t/ �) ✓LPA 22) <br />Business Address: Zf9533 wl . Hyyq qci t ACa mpe 0 CA 9 5110 <br />n <br />Mailing Address (if different from above): Y1rpP. <br />n <br />Nature of Business: t IV 11�t VICCi i, r Fire District: n <br />Q1. Yes ONo Does your business handle a hazardous materiai 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. )QYes ONo 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 />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 only 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 kNo Does your business handle an acutely hazardous material? See definition on reverse <br />side of this form. <br />Q4. DYes 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. 1 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 Auu�thorizryled Agen <br />X LI old Date: Z- <br />,' tNam �U?rlf' 1r <br />X t, Title:_ _ V <br />Signature <br />