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RECEIVED <br /> MAR 3 0 2007 <br /> oPgUlN COUNTY OF SAN JOAQUIN 94"MWO AE6 <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> �. .< ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> • r... P• STOCKTON, CALIFORNIA 95202 <br /> TELEPHONE(209)468-3962 <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 name <br /> and/or address in San Joaquin County is required. <br /> Business Name: ,V_ c4adi2 o aK-177fi�1U , /-LC <br /> Business Owner(s)Name: Anc9(� rC�KoT�f 1 -�11 Telephone: © QCJtJ� <br /> Business Address: 1dZS QtN1UltN/ 1)m/a- Srpcgc�d(1 GA q176 Ll <br /> Mailing Address(if different from above): 567 Ccx mXS 'ck)-6,0, C�?6q <br /> Nature of Business: WQTC` BoAl Fire District: <br /> Q1. Wes DNo 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. Yes []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 200 cubic 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 /> ❑ A. 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 /> B. This business is a health care facility (doctor,dentist,veterinary,etc.)and uses only medical gases. <br /> J C. This business operates a farm for purposes of cultivating the soil,raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. (7Yes a o� Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes nl o 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. 1 understand that if I own a facility or property that is used by tenants,that it is my responsibility to notify the tenants of <br /> the 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 Authorized Agent: <br /> X Z Dh r <br /> R vAnS.t!.1 Date <br /> Print Name <br /> g itle <br /> gnat low <br /> 06, <br /> lm� t ev 10/96) <br />