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` RECEIVED. <br /> COUNTY OF SAN JUIN <br /> AUG 18 2010 <br /> OFFICE OF EMERGENCY SERVICES <br /> K: o <br /> 2101 E. Earhart Avenue, Suite 300 SAN JOAQUIN COUNTY <br /> Stockton, California 95206 OFRCE OF EMERGENCY SERMCES <br /> (�0�C 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. <br /> Business Name: � `x S� SNC <br /> Business Owner(s) Name: /�.fy C. 1C "� T�c rA- c:.. J�Rp ) Telephone: ;2°'+- yZ-.fid°�rl <br /> Business Address: <br /> Mailing Address (if different from above): <br /> Nature of Business: 151—x .. Fire District: <br /> Q1. 'P(Yes ❑No 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. 'piyes ❑No 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? <br /> If"Yes," check any of the following conditions that applies to your business. <br /> )K4. 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 /> ❑B. This business is a health care facility (doctor, dentist,veterinary, etc.) and uses only medical gases. <br /> ❑C. This business operates a farts for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3.*Yes ❑No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑YesykNo 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 of cxy Date: <br /> Prinry me <br /> X T Title: <br /> tu Signature <br />