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cn <br /> X • p� s r <br /> l'A /�e S•.} X'Ar Ae.r A4 e_ <br /> ip ,*/Ill b� ,2u�`o d��Fwc�.� Q�y.Tiea✓ u�q'.rIEG?P�- <br /> Q.4�,rr. COUNTY OF SAN JOAQUIN <br /> a� OFFICE OF EMERGENCY SERVICES RONALD E.aALDWIN <br /> ROOM 610,COURTHOUSE DIRECTOR OF <br /> 222 EAST WEBER AVENUE Elffv OPERATION <br /> STOCKTON,CALIFORNIA 95202 D <br /> • {�IF3t+`'�' TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 OCT - 6 2000 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> SAN JOFQUIN COUNTY <br /> .,.:"" SERVICES <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business nam <br /> and/or address in San Joaquin County is required. <br /> Business Name: Cozad Trai 1 er . Sales LLC <br /> Business Owner(s)Name: . Delores Hutcheson Telephone: ( 209 ) 931 -4093 <br /> Business Address: 3206 N . Cherryl and Avenue Stockton 95215 <br /> Mailing Address(if different from above): 4907 Water10o Road Stockton 95215 <br /> Nature of Business: Iowbed trailer manufacturing/service Fire District: Waterloo-Morada <br /> Ql. EXYes ONO 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. LDYes LINO 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? ' 19 7 3 <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 /> ❑ C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes K]NO Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes I%]No 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 <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 /> g res Hutcheson A Date 08/30/00 <br /> Are <br /> ' Title Owner <br /> Signature (Rev 4/99) <br />