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QC^c e <br /> ED <br /> a: FEB 27 2003 <br /> :r�r�votti"� &"Id INCOUISeY <br /> COUNTY OF SAN JOAQUIN 1F16E00RI ENCHSF'ir CE <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> 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 <br /> name and/or address in San Joaquin County is required. <br /> Business Name: QYCO <br /> rt+�crcr F/}NbpRp�7E Telephone: � q49 -ZySZ <br /> Business Owner(s) Name: <br /> Business Address: <br /> 225D STEWAKT ST *JSTDG G4 �5?GLS <br /> Mailing Address(if different from above): <br /> Nature of Business: D15MAJTD�1CONs>R�T10� /��AL Fire District: T Syler C< OF S7A'k7ebJ <br /> ty at any <br /> ne me in the <br /> Q1. [ yes ❑No yyear?ySeethe definitiondle a hazardous material of hazardous mate ial andn any the back of this o <br /> Doesourusiness this form. if your answer is <br /> No,"go to Question 4. <br /> xture <br /> a hazardous <br /> Q2. es ❑No Does material in a quantity equal to oyor business handle a ar greater thzardous an gallons, pounds, org200cubic feet at <br /> any one time in the year? <br /> 1998' <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 /> OA. The hazardous materials handled by this business is contained solely in a consumer product, <br /> packaged for direct distribution to, and use by,the general public. <br /> 1713. 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 <br /> agricultural or horticultural commodity. <br /> Q3. OYes *o Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> 04. DYes *�vo Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 have read the Information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code. I understand that If I own a facility or property that Is used by tenants,that it Is my responsibility to notify the <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I <br /> declare under the penalty of perjury that the Information provided on this disclosure survey is true and accurate to the best of <br /> my knowledge. <br /> Owner or Authorized Agent: <br /> X /OVJAM Date: 211*103 <br /> rint e <br /> x�i f Title: <br /> Signature <br /> Sl�N�D SCS lNa�n��l>,f <br />