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- <br /> r <br /> 7; �1 <br /> 4�1CO.R�i <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> Telephone (209)468-3962 <br /> Hazardous Materials division (209) 468-3969 <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 Name: f� <br /> Business Owner(s) Name: ._11,dro A_0Z_C_0 Telephone: <br /> Business Address: J7 /ADD �-l11� 3�27 6A4;( v[ice <br /> Mailing Address (if different from above): <br /> Nature of Business: Fire District: <br /> Q1. ❑Yes PIC Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on the back of this form. If your answer is <br /> No,"go to Question 4. <br /> Q2. ❑Yes Does your business handle a hazardous material, or a mixture containing a hazardous <br /> material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at <br /> 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 /> CIA. 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 oar medical gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agric.u.ifural or horticultural commodity. <br /> Q3. ❑Ye's Does your business handle an acutely--hazardous „material? See definition on reverse <br /> side of this form. <br /> Q4. U3 es ❑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 4rm and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code. I understand that'iftwn 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. I <br /> declare under the penalty of perj r�that the information provided on this disclosure survey is true and accurate to the best of <br /> my knowledge. <br /> Owner or Authorized Agent: <br /> X pew Q <br /> _ Z(—'o ,_..._.. Date: � <br /> X P nt Na _ <br /> Title:__LTA) <br /> gna re <br /> i <br />