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lkwliO COUNTY OF SAN JOAQdtN <br /> j'° � OFFICE OF EMERGENCY SERVICES <br /> l \' 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 San Joaquin County is required. <br /> Business Name; _Li <br /> Business Owner(s) Name: I <br /> Telephone; <br /> Business Address: Uhf - t <br /> Mailing Address(if different from Iabove): ( .' t L'_l <br /> Nature of Business:r O t iGj tt�} �{iy 1 tn_ -- <br /> �t <br /> __ Fire District: <br /> Q1. OYes V6o Does your business handle a hazardous material in any quantity at any one time in the ear? <br /> See <br /> definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. the <br /> Q2. OYes oNo 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 /> tf"Yes,"check any of the following conditions that applies to your business. <br /> OA. 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 /> 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 /> D3. OYes ONo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> D4. OYes oo Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 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 /> enants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations I <br /> feclare under the penalty of perjury that the information provided on this disclosure survey is true and ;iccurate to the best <br /> )f my knowledge. <br /> owner or Authorized Agent: {{^^ <br /> 11%t Date: <br /> 0'41rNam <br /> 0FV.1vMPmnmv..n,.,.,.,ems....�............ ...... ... _ _ -- ., _ _ <br />