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10 o�S RECEIVED <br /> �:¢_ •!n` a` J COUNTY OF SAN JOAQUIN JUL 9 — Zol� <br /> OFFICE OF EMERGENCY SERVICES <br /> 1 \ 2101 E. Earhart Avenue, Suite 300 SAN JCA(lUIN COUNTY <br /> Stockton, California 95206 pFflCE OF EMERGENCY SERVICES <br /> Telephone 209 953-6200 <br /> FAX(209)953-6268 <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. p <br /> Business Name: �y' �� I V`IaJe' x ��w�CJ' U-1 <br /> Business Owner(s)Name:�A o-I- I f-cL je k C e y4ey-, LLC— Telephone: AI \ 5 - 4 Tit <br /> Business Address: Maa ry +ov% -R�, L ca; . Q A (35-1-%A1 <br /> Mailing Address(if different from above):7,Q.aoxlOLLA L. �,:TgxDeo�_K\woXvi;tip- <br /> "+c41 So.\Co-F wcimorf„et,fas+ ��d, <br /> Nature of Business: $ \dM/en:awes coo r,L i+ev..s Fire District: ; <br /> Le- <br /> Q1. )(Yes ONo Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br /> of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2. )dyes ONo 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 200cubic feet at any one time in the year? <br /> If"Yes,"how long have you handled these materials at your business? '7 t 1 Zol o <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, packaged <br /> 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 agricultural or <br /> horticultural commodity. <br /> Q3. OYes TJ 0 Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes*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 : 1A('ll ev%r tA- Date: 6"LS=ICJ <br /> X i _� _ Title: S en i Or V P <br /> Signature <br /> F.\DevSvdPlanning AppNcatlon Forms\Business License(Revised Ot-25-10) Page 4 of 7 <br />