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F COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> Telephone (209)468-3429 <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 <br /> Name: Igo �tA o Rt pad r <br /> Business Owner(s) <br /> Name: �A��v p 1j p� Telephone: 3 <br /> Business 4W <br /> Address: 331 N WlLS4rJ WyI f sL TJ _C* <br /> Mailing Address (if different from <br /> -above): 341-6 t d M Y O A t (/j ° A PC. 4044tJ AA qi 106f <br /> Nature of <br /> Business: Fire District: <br /> Q1. Oyes f'No 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 I 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 /> ❑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 /> 013. 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. ❑Yesflo Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> 04. ❑Yes Pi o 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. 1 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. t <br /> Owner orAuthgQQr' ad� rs gent: +0Ip <br /> X �oA?Z 17 Date: Oq 10 <br /> Pripilt Name <br /> X 4L 14. Title: Q .Plr° <br /> g dtre <br /> F/ApplicationsFor s&HandoutslPlanningApplimtionsBusiness License(Revised 02-24-15) <br /> 0� AofF <br />