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_ May 26 2006 3: 17PM PROACTIVE PKG. & nISPLAY 9096052950 <br /> p. 4 <br /> • v <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 Son <br /> ��Joaquin <br /> /County is required. // <br /> Business Name: PA)6- PWa 'rt+G. tor74re �bK¢c,•t «er- <br /> BusinessOwner(s)Name: G �26e'�- CfyS n . Telephone: <br /> Business Address: y_3 y3 E. reg 0n 1- ' fo CP4- <br /> 9 ass <br /> Mailing Address(if different from above): _ <br /> Nature of Business: fy6fty j,., ,_0- _(:N r Aj—ca-4e1—t-- :ire District: <br /> Q1. ,Yes ONo 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 /> 02. ❑Yes )(No Does your 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 200cubic feet at 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 hezardous 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 /> OB. This business is a health care facility(doctor, dentist,veterinary, etc.)and uses only medical gases. <br /> OC. This business operates a farm for purposes of cultivating the soil,raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes 1dNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes JWNo 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 5.95 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 <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> Xy�^ ^ S C-o D. Date: <br /> PP t erne �� J <br /> X_ e, Title: �• �. _ _ Q/J,r',r-a Y7 o. S <br /> S nature <br /> F0EVSVC1PIenn1ng Applicatlon Fo"SkS@eAppro 1.(Re, sWd"3 S) Page 5 of 9 <br />