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COUNTY OF SAN JOAQUIN REGEIVE>) <br /> OFFICE OF EMERGENCY SERVICES FEB 12 2010 <br /> 2101 E. Earhart Avenue,Suite 300 <br /> N STOCKTON,CA 95202 C�CEANJOApC/NCCU <br /> ELEPHONE(209)953-6200 OF E41EgGENCYSERVICES <br /> B <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 and/or <br /> address in San Joaquin County is required. <br /> Business Name: I�JJ�" GY� <br /> (1 n it-& p G ���E�—� Telephone: <br /> Business Site Address: 115 3 k S <br /> Mailing Address(if different from above): <br /> Telephone: <br /> Business Owner(s)Name: <br /> Business Owner Address: <br /> Nature of Business: 'Rj1k1C (, MO-S Fire District: <br /> QI. es o 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. ElYes ❑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 operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3.- E]Yes []No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. []Yes �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. 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 Authorized Agent: <br /> X Date <br /> Pri / p <br /> X Title <br /> ig atur <br /> (Rev 8/OS) <br />