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COUNTY OF SAN JOAQU.IN <br />Environmental Health Department <br />1668 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 />RECEIVED <br />FEE,' a ? 201? <br />L" WIRONILlE-MAL H -A:+ Til <br />PEAM1T/vE,Tvr,I b <br />please read the intoss ,,at a^ o th,e rS�va e so,& before rom, Meek;,iwu %,s susve�j i-wm. A Separate susvw j %1 each Wu ness <br />name andfor address in San Joaquin County is required. <br />Business <br />Name: _ &,Alec. <br />Business Owner(s) <br />Name: �%kt L?/V� Telephone: _ <br />Business <br />Address: <br />/4/k .� / -c'i% �� S'/ 11 Cly i �,, ��} 7j,;:7 <br />Mailing Address (if different from 1 <br />above): � 17 � ' s;- ky jr I L(.... i'L.-OADO <br />C���./4� <br />Nature of <br />Business:2�/--� Fire District: e C u <br />Q1. 1 (Yes ❑No Does your business handl 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. s6es ❑No 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 Iona have you handled these materials at vour business? d wt.c)"L aO <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, <br />packaged 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 <br />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 *o Does your business handle an acutely hazardous material? See definition on reverse side of this <br />form. <br />Q4. ❑Yes 9910 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 <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 />Owner pr Author i d Agent:/ <br />X ✓I.r� Date: /2_l% -/tor <br />NVq <br />X Title: <br />nature <br />F/Applic ionsForms&Handouts/PlanningApplications/Business License (Revised 02.24-15) <br />Page 4 of 6 <br />