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0 <br />oP�'•p'IN c <br />Q: <br />i <br />9C/PORN <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 />RECEIVED <br />DEC 1 ' 2007 <br />OFFICE E <br />N OAOUIN COUNTY <br />NfERGENCY SEiVICEE <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�,SXL -e 7xI,tCl– (�(C <br />Business Owner(s) Name: <br />Business Address: <br />c <br />Telephone: `�_� -•may%–�'�Y� <br />Mailing Address (if different from ? ` (0`�2above):` 7 <br />Nature of Busine4fLI <br />: -��Ck �C�As 2 ( I Fire District: -v A <br />Q1. PYes D No Does your business handle a hazardous material in any quantity at anyone time in the year. Seethe <br />definition of hazardous material on the back of this form. If your answer is "No," go to Question 4. <br />Q2. OYes D 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? // LL&—Iq� <br />If "Yes," check any of the following conditions that apply to your business. <br />EgA. 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 />DB. This business is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical gases. <br />DC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br />horticultural commodity. <br />Q3. <br />DYes <br />filo <br />Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br />Q4. <br />DYes <br />ONo <br />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 />#125(Rwis 1636021 <br />Pape 4 of 5 <br />Date: <br />Title: <br />