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q ._G <br /> .}- COUNTY OF SAN J44*i�lN <br /> p4u�" OFFICE OF EMERGENCY SERVICES <br /> Room.610. Courthouse <br /> 222 East Weber Avenue <br /> Stockton. Cahforrna 95202 <br /> �dl �on Teleph6ne (209}468_3962 <br /> Hazardous,Materials Divistor}.(2D9)46&3969 <br /> N R <br /> Ate# DOM <br /> US ATERIAL� <br /> S DIS.CLOS.URE SURVEY <br /> Please read the�nforrnattoa on the reverse side,before%completing this syivey form:. A separate survey for each business <br /> name'and/or°address m San.toaqum County is''required. <br /> Business Name, C;n il✓-�� ' <br /> Business Owner(s)..Name: Telephone: <br /> Business Address: <br /> Mailing Address,(if different from above); <br /> Nature of.Business: Fire District: <br /> 7 <br /> Q1. ❑Yes�No 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. ❑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 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 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. ❑YesClo Does your business handle an acute) hazardous material? See definition on reverse side of this form. <br /> Q4. 1�Yes []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 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 <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> X Date: 2 r <br /> ame <br /> X Title: <br /> 1011 Z Signa ure <br /> I <br /> RTEVSMRanning Application Forms\She Approval.(Revised 13-03) Page 6 of 9 <br />