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COUNTY OF SAN;JOPQ IN <br /> Environmental Health Depa4n int <br /> 1868 E Hazelton Avenue <br /> Stockton,California 9520$ <br /> Telephone(209)458-3420 <br /> FAX(209)468-3433 <br /> Website:www.sjgov.org/eMd <br /> 1 I <br /> HAZARDOUS MATERIALS DISCLOSUII,R (SURVEY <br /> Y qcompleting _is suw I,. p y dr each business <br /> Please read the information on the reverse side before this su a orm. Ase crate survey f <br /> name ani)/or address in San Joaquin Count is required. <br /> Business <br /> Name: � <br /> Business Owner(s) <br /> Name: I Telephone: <br /> Business II <br /> Add ess: ��o4 STMI�rJ �� 13AY TI IZI;. C0. <br /> ). <br /> ZZ66 <br /> Mailing Address Kif different from UNIT C <br /> above): FIELD,CA 91531— <br /> Nature of <br /> Business: Fire District: <br /> Q1. OYesRINo Does your business handle a hazardous material in any qu Illy at'any onetime in the year? Seethe <br /> definition of hazardous material on the back of this form I ur answer is No,"go to Question 4. <br /> } Q2. OYes L�INo Doers your business,handle-a hazardous material,or a ix a containing a hazardous material in a <br /> '\ quantity equal to or greater-than 55 gallons, 500 pound ,.o 00cubic feet at any one time in the year? <br /> if-' es,-how long have you handled these materials at u �usinP s?_�_ <br /> If check any of the following conditions the t applies t your business. <br /> I <br /> OA; The hazardous materials handled by this business is c ntained solely in a consumer product, <br /> packaged for direct distribution to,and use by, th g n rel public. <br /> OB, This business s a health caro facility(doctor,den'st, l terinary, etc,)and usis o f medical <br /> gases. <br /> i r <br /> OCr This business operates a farm for purposed of cut iv i g the soil,raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> 3. ❑Yes o Do °s your business handle an acute) hazardous m to 18 See de'f'inition on reverse side of this <br /> Q I� q <br /> forth. ' <br /> Q4. DYes %No Is your business within 1,000 feet of the outer boundary lof chool(grades K-12)? 1 <br /> 1 have read the information on this form and understand my requirements n Chapter 6.95 of the California Health and <br /> Safety Code. I understand that if I own a facility or property that is used b to ints, that itis my responsibility to notify the <br /> ents which mus be met prio <br /> tenants of the require Dr to issuance of a Card is of Occupancy or beginning of operations. <br /> I declare under the PepWly of perjury the information,Provided pn Ibis is sure survey is true antl apcurate to the <br /> best of my know) e' <br /> Ow e or A t: <br /> x i ate:-- _._. <br /> X R TiBe: <br /> at e <br /> FlAppgcatlunsFOmrs&Hantdoul to ningApjAcettonVBuVr&ss License(Revise]02-24-15) 1 <br /> Page 4 of 6 <br />