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i <br /> COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> Telephone(209)468-342-0 <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,sutvey form. A separate survey for each business <br /> name anWor address in San Joaquin County is required. <br /> Business <br /> Name: <br /> Business Owners) <br /> Name: { (� ([ ]J, M Telephoner <br /> 1.5 t_O <br /> Business �1 <br /> Address: <br /> Mailing Address(if different from 9 <br /> above): <br /> Nature of <br /> Business: Fire District: <br /> Q1. ❑Yes,*o Does your business handle a hazardous material in any quantity at-any one time in the year?-Seethe <br /> definition of hazardous material on the back of this form. if your answer is No,"go to Question 4. <br /> Q2. ❑Yes 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 /> OA. 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 fGo`; Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> 04. []Yes ❑No 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 or A thprazed Agent: n r <br /> X ! Date:_ `�--} �l �• <br /> r hN e x <br /> X Title:_ . <br /> — � i <br /> � .Signature <br /> F/ApplicationsForms&Handouts/PlanningApplications/business License(Revised 02-24-15) <br /> Page 4 of 6 <br />