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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 Easf Weber Avenue <br /> Stockton, California 95202 <br /> Telephonei1209)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 /> r Business Name:. f1 <br /> Business Owner(s)Name: L--&-T14 Telephone: <br /> Business Address: 700 C-4, <br /> Mailing Address(if different from above): <br /> - I <br /> Nature of Business: EL-E G0N7�T�Fire District: <br /> Q1. ❑Yes I No 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 ❑ 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 /> 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 /> ❑B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses pDly medical gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil, ralsing, 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 /> XYes <br /> side of this form, <br /> Q4. ❑No 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. 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, I <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. <br /> Owner or Autho rd Agent: � ' <br /> X <br /> Print Name <br /> XC L��� T, Title: I <br /> Signature <br /> I . <br /> l <br /> o- <br />