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COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> Telephone(209)468-3420 <br /> FAX(209)468-3433 <br /> Website: www.sjgov.org/ehd <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 f� <br /> Name: ` Y e <br /> Business Owner(s) (2oq) $to- S 7 56 <br /> Name: �nl 11 r-`�nY��YY Z Telephone:C2eSIS— <br /> Business <br /> ��S <br /> Business t <br /> Address: 12-60 htkf lk S� SAXtNOY1 Cwt (15205 <br /> Mailing Address (if different from <br /> above): <br /> Nature of <br /> Business: Fire District: <br /> Q1. W(es 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. OYes ONo 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 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 /> 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 /> OB. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical <br /> gases. <br /> OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. OYes 3No Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> 04. OYes PZNo 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. <br /> I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge. <br /> Ow�qer r Aut orized A��ggnt: <br /> x K� ��yi�CYrL Date: 11-1d- 17 <br /> Print me • <br /> X tr* aC'f Lf �'� �'z Title: LISNyless owi\n Y <br /> Signature <br /> F/Applic bonsFonnsBHandoutstManningApplic bons/Business License(Revised 02-2415) <br /> Page 5 of 7 <br />