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uo rb -iAmwlf iv <br /> RECEIVE® <br /> APR 01 2 2014 <br /> COUNTY OF SAN JOAQUIN <br /> omm OF EMERGENCY SERVICES E NIR0NMENTA4HW H <br /> 2101 E.Emhart Avenue,Suite 300 PERMIT/,SERVJCES <br /> STOCKTON,CA 95202 <br /> TELEPHONE(209)953-6200 <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 name and/or <br /> address in San Joaquin County is required. <br /> �l r _Telephone: <br /> Business Name: !/✓q�0y+. 1;1 yo d�� � � r <br /> SS s� e C4 Q�2 � <br /> Business Site Address: P� <br /> Mailing Address(if different from above): _ b <br /> Telephone: <br /> Business Owner(s)Name: Imavincul, <br /> Business Owner Address: l <br /> Fire District <br /> Nature of Business: ear? Seethe <br /> Wes o Does your business handle a hazardous material in any quantity at any onetime i, the y <br /> QI �, oto Question 4. <br /> definition of hazardous material on the back of this form. Ifyour'snswer is"No",g <br /> ng a hazardous material,in a 7 <br /> Q2. Dyes '®No Does your business handle a hazardous material, ror 200 cubicre �feet at any onetime in the year• <br /> quantity equal to or greater than-55 gallons,500 pounds, <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 /> ❑ 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 generalpublic. <br /> Q B. This business operates'a farm for purposes-of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commudity: <br /> al7 See defirrn10n on reverse side of this form- <br /> Q3. Yes CgKo Does youi business handle an Acutely Hazardous Mated <br /> Q4. Dyes [4No is your business within 1,000 feet of the outer boundary 9f a school(grades K-12)? <br /> I have read the information on this form and understand my requirements under Chapter i6s of the California Health te antafety <br /> of e <br /> Code. I understand that if I owh a facility or property that is used by tenants,that rt is my res of operationsoinsibilitY to.I declare under the <br /> - requirements which must be met prior to issuance of a Certificate of Occupancy and aco:rbegcurate <br /> Pe knowledge. <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my <br /> Owner or Authorized Agent <br /> d Date `I <br /> X <br /> Print Natafe <br /> erns) <br /> VVA)* <br /> \,,^� <br /> V l <br />