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../ City Bldg Dept <br /> : �5 -aati <br /> Application# <br /> COUNTY OF SAN JOAQUIN <br /> RONALD L aALowiN <br /> c OFFICE OF EMERGENCY SERVICES COORDINATOR <br /> 7 ROOM 610,COURTHOUSE <br /> AVENUE afi•.' . 222 EAST WEBER AVENUE RECEIVEC <br /> STOCKTON,CALIFORNIA 95202 <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 MAY 4 7 2015 <br /> HAZARDOUS MATERIALS SURVEY FORM <br /> ENVIR®N,YENTAt <br /> Please read the information on the reverse side before completing this survey form. A separate•sury ofi a- <br /> business name and/or address in San Joaquin County is required. <br /> Business Name: <br /> Business Owner(s)Name: f Telephone: ( <br /> Business Address: <br /> Mailing Address (if different from above): <br /> Nature of Business: Fire District: <br /> Q 1. ❑Yes [!rNo 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. ❑Yes [Ko Dees your business handle a hazardous material,or a mixture containing a hazardous material,in a quantity <br /> equal to or greater than 55 gallons,500 pounds,or 200 cubic 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 /> ❑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 general public. <br /> ❑B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses only medical 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 [/�No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes El'No Is your business within 1,000 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 Safety <br /> Code.I understand that if I own a facility or property that is used by tenants,that it is my responsibility to notify the tenants of the <br /> requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations, I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Own4er�or Authorized Agent: <br /> X �1( \S�O� ` `�]t�J \fNo,: Date 441101[S- <br /> Pint <br /> 41<QtiS- <br /> Pint Name J <br /> X �L�. a-21� `L 1�l 1l `vC�. Date � <br /> Signature <br />