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e <br /> • COUNTY OF SAN JOA•QUIN <br /> • •? OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse RECjLi°vD <br /> 222 East Weber Avenue <br /> • �q .... .. P • Stockton, California 95202 DEC 2 0 6 <br /> Telephone(209)468-3962 COUNTY <br /> CO <br /> Hazardous Materials Division (209)468-3969 OFFICE OF SAN JUAUUIN UAUUINEIVERGECO SERVICE: <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 /> I <br /> Business Name: <br /> Business Owner(s) Name: Telephone: <br /> `.-Business Address: ��� �YCfit66A7 <br /> Mailing Address (if different <br /> /from above): PGX C7 V161 <br /> Nature of Business: wlV I� N Fire District: <br /> Q1. ❑Yes ©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. OYes <?No Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons, 500 pounds,or 200cubic feet at 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 /> 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 MNNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes MNo 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. I 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 <br /> of my knowledge. <br /> Owner or Authorized Agent/: <br /> X_ l.�L� — -�U✓ice�'°— _ Date:_ — <br /> Na <br /> 7( Title:_ <br /> Signature <br /> F:\DevSvc\Planning Application Fonns\Business License(Revised 10-20-05) Page 5 of 8 <br />