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k 0 <br /> p PA - 0300676 <br /> w <br /> ••*YID HNL'• <br /> COUNTY OF SAN JOAQUIN �c� � <br /> OFFICE OF EMERGENCY SERVICES A <br /> Room 610, Courthouse <br /> 222 East Weber Avenue pN - g 2004 <br /> Stockton, California 95202 <br /> FrySG fWbwl£RSriEPGL"',,,yTelephoneJ209)468-3962 yS[. t E <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: u cC n l o p g <br /> Business Owner(s)Name ,:2 n'^ !� jA�'�``� a r tOnT�elephone: <br /> Business Address: 4 J '/W�L "' <br /> Mailing Address (if different from above): <br /> Nature of Business: Ao� Fire District: <br /> �- n the <br /> Q1. OYesB No yyear? See the definition of hazardous material on the any <br /> acback of this fat one time l form, f your answer is <br /> No;go to Question 4. <br /> 02. Yea -qNo 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 /> ❑B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses only medical gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes No Does your business handle an acutely hazardous material? See definition on reverse <br /> \ side of this form. <br /> Q4. ?yes ❑No 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 propertylhat 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 /> X I R Q9 `�" Date: I (� <br /> nt N e <br /> X Title: Grna� <br /> S <br />