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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 /> r Please read the information on the reverse side before completing this.survey form. A separate survey for each business <br /> name anWor address in San Joaquin County is required, <br /> Business <br /> Name; ) _ L ),� ��� t , <br /> Business Owner(s) <br /> Name: � A <br /> �(� ti Te12�L �De <br /> Business �' <br /> r <br /> Address: <br /> Mailing Address (if different from <br /> above): Aw VAIx2. <br /> Nature of <br /> Business: ` i e Istrict: N1,J", <br /> Q1. ' Yes CJNo Does your business handle a hazardous material in any quantity at-any one time in the yearT See the <br /> definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2. i'es ❑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 long have you handled these materials at your business? <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> 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 olC 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 *o 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 /> 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 /> Owner4//Authoriz Agent: J` <br /> 6��^/7� ���-� - Date: <br /> Pr t Name <br /> Title: <br /> Signature <br /> F/ApplicabonsForm s&Handouts/PlanningApplications/Business License(Revised 02-24-15) <br /> Page 4 of 6 <br />