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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East•Weber Avenue <br /> Stockton, California 95202 <br /> TelephoneJ209)468-3962 <br /> Hazardous Materials Division (209)468-3969 <br /> HAZARDOU§MATERIALS DISCLOSURE SURVEY <br /> i ! I <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 r quired. <br /> Ir <br /> Business Name: !,, II <br /> l Business Owner{s) Name: VJ 6�� Telephone: -� <br /> � Business Address: <br /> GSZ-r. <br /> i <br /> Mailing Address(if different from above): <br /> INature of Business: Fire District: <br /> Q1. ❑YesNo Does your busines 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 NO 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 /> 1 If"Yes,'check any of the°following conditions that applies to your business. <br /> i ❑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 /> I <br /> 1313. This business is a health.cui e'facility(doctor,'dentist;veterinary,etc.)and uses only medical gases. <br /> Cit This business operates a':farm or 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 <br /> side of this form. <br /> Q4. ❑Yes No Is your business within.1;000 feet of the outer boundary of a,school (grades K712)? <br /> i <br /> I have read the Intormatlon on this form and understand my-requlrements under Chapter 8.95 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 ere uirerrtents which ntu t be met prior to;issuance`of a Certificate of,Qccupancy or,beginning of,operations. I <br /> declare der th penalty of perjury. at'ihe information provided on this disclosure sunvey.is true and accurate to the best of <br /> my kn . ge. <br /> e u ed Agent: <br /> XDate:. <br /> r Print Name <br /> X Title: 1 - <br /> Signature <br />