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+ 3 <br /> r• � it - <br /> {�r. COUNTY OF,SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 690, Courthouse I <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> �j TelephoneJ209)468-3962 <br /> Hazardous Materials Division (209)468-3969 <br /> i HAZARDOUS MATERIALS DISCLOSURE SURVEY �+ <br /> ` Please read the lnformatlo ii 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: <br /> g �} Z 739Telephone- <br /> Business <br /> Owner(s) Name:� <br /> Business Address: ] g <br /> Mailing Address(If different from above): f.d <br /> E! t� <br /> Nature of Business: Fire District:_ OTS' t 'C i�ie 1C V. <br /> Q1. ❑Yes 0,Na 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 /> u `I <br /> zardous <br /> 02, f]Yes No Does, a hazardous <br /> material In a quantity equal to oour business handle a r material, <br /> r gr ater than 55gallons,�500 pounds,lorg200cubic feet at <br /> any one time In the year? 4 <br /> if"Yes;how long have you handled these materials at your business? <br /> j If"Yes;check any of the following conditions that applies to your business. <br /> QA. I The hazardous materials handled by this business is contained solely In a consumer product, <br /> 1 I 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 gases. <br /> E <br /> ` ❑C. . �i This business operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> I <br /> Q3. ❑Yes *o ,' Does your business handle an acute/ hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. '0Yes ❑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 8.95 of the California Health and <br /> Safety Code. I understand that If I own a facility or property khat is used by tenants,that 11 is y responsibility to notify ha <br /> Certificate of Occupancy or beginning of operations. 1 <br /> tenants of the requirements which must be met prior to issuance of a <br /> declare"under the'penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of <br /> my knowledge. t <br /> Owner or Authorized Agent: <br /> X orio e L'aS. QA Date: <br /> Print Nam <br /> X — Title: ti ^Ct I <br /> Signature <br /> II <br /> 1 - <br />