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L <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD F-BALDWIN <br /> �• '.o <br /> 2 = ROOM 610,COURTHOUSE DIRECTOR OF <br /> m: a <br /> 222 EAST WEBER AVENUE F-MERGE`CY OPERATIONS <br /> �* STOCKTON,CALIFORNIA 95202. <br /> *Vi oRN TELEPI4ONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> j Please read the information on the reverse side before completing this survey form. A separate survey for each business name <br /> I, and/or address in San Joaquin County is required. <br /> Business Name: <br /> —Tf— <br /> Business Owner(s)Name:._ L�°" �� - -_ - Telephone: <br /> Business Address: � � 94e 9.._ `-10C -J <br /> Mailing Address(if different from above): S� <br /> Nature of Business: EZ2 f0 _- >_AliFire District: <br /> Q 1. !=Yes KNo Does,your business handle a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material on the back of this form. If your answer is"No",go to Question 4. <br /> Q2. E.-Yes ONO DoesY our 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 200 cubic feet at any one time in the year? <br /> 4 <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 packaged for <br /> direct distribution to,and use by,the general public. <br /> h 'lit (doctor dentis veterinary,etc. and uses I medical gases. <br /> ❑ B. This business Is a health care facility( oc , t, ary, ) on v <br /> ❑ C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural-or horticultural commodity. <br /> Q3. ❑XYI,C <br /> Yes ❑No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. s ONO Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? <br /> t I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br /> Code.Tunderstand that if I own a facility or property that is used by tenants,that it is my responsibility to notify the tenants of <br /> the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information.provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> / Cfv Z <br /> X .� L� t Date <br /> Print Name <br /> X <br /> Signature (Rev 4199) <br />