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a "r, COUNTY OF SARI JOAQUIN <br /> Environmental Health Department <br /> <l 1868 E Hazelton Avenue <br /> Sior-Mon, California 95205 <br /> �- Telephone (209)468-3420 <br /> FAX (209)468-3433 <br /> Website: www.sjgov.org/ehd <br /> HAZARDOUS MIATERIALS 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 /> BusinessName: <br /> Business Owners)Name: —EI36, Of— l r yit <br /> � I )Telephone <br /> r <br /> Business Address: <br /> Mailing Address (if different from above): <br /> fare of Business: Fire District. 1 — <br /> Q1. MYes —! 2F,V , <br /> IIKo 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 /> f <br /> Q2. []Yes ffho 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 204cubic feet of 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:hat 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 /> QB, This business is a healthcare facility(doctor,dentist veterinary, etc_)and uses only medical gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. ❑Yes l!rNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> 04. QYes two 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, t 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 A orized ent: <br /> # Date: t, 9-IP- 12) <br /> ongt til"�, Titter JheX <br /> SRRignature - - <br />