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• RECEIVED <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 />DEC 112008 <br />SANJOAQN <br />O <br />FFICE OF EMERgEN�Oy UN SERVICES <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: "- ?-)uMGA2�►�. I'Ae <br />Business Owner(s) Name: eLAZ2 C- Telephone: 425- 3'15- 19$6 <br />Business Address: 3291 So I4wY 99 �.- C -A 9Sz1S <br />i <br />Mailing Address (if different from above): Q O So 190 Srocy-we, Gb 95 21,3 <br />Nature of Business: Fire District: Ho "rfE 2ti+µA <br />Q1. gYes J,No Does your business handle a hazardous material in any quantity at any one time in the year. See the <br />definition of hazardous material on the back of this form. If your answer is "No," go to Question 4. <br />Q2. KYes O No Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br />equal to or greater than 55 gallons, 500 pounds, or 200c any one time in the year? <br />If "Yes," how long have you handled these materials at your business? 21 y ar+.-$ <br />If "Yes," check any of the following conditions that apply to your business. <br />OA. The hazardous materials handled by this business is contained solely in a consumer product, packaged for <br />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 agricultural or <br />horticultural commodity. <br />Q3. OYes 0INo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br />Q4. OYes XNo 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 ^Affuthorized Agent: <br />SLA (Ltt E31.JG �- Date:- <br />X �r <br />X I /intN>--T I , '-Ri5rfairam <br />�-'(J Title: <br />