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COUNTY OF SAN JOA.,-,, IN <br /> P N OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> •., ;4 <br /> Telephone (209) 468-3062 <br /> Hazardous Materials Diyision.(269) 468-3569 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> please read the Information on the reverse side before completing this survey fbrm. A seOafate survey for each business <br /> name and/or address in San Joaquin County is required. <br /> Business Name: <br /> RF��LEAS CO�a �1�i^t o <br /> fRf��AS ZO`I-bb9 �I t9 <br /> Bus(nes5 Owners) Name: Telephone: <br /> Business Address: 1TXT� ft TS 3 <br /> Mailing Address (if different from above): 0 <br /> n^ -jv 2W ct-r C4 75�'0 <br /> Nature of Business:��C� � 1��t11L _ �lST2t$dilo�l Fire District: <br /> Q1. (6Yes pNo Does your business handle a hazardous material in any quantity at any onetime in the year? See the <br /> /-N definition of hazardous material on the back of this form. If your answer is No,"go to Question 4, <br /> Q2. 116yes 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 20Ucubic feet at any one time in the year? <br /> If"Yes,"how long have you handled these materials at your business? 6(3-� `�S <br /> if-yes,- check any of the following conditions that applies to your business. <br /> lA. The hazardous materials handled by this business is contained solely in a consumer product, <br /> 11�� packaged for direct distribution to, and use by, the general public. <br /> [I a. This business is a health care facility (doctor, dentist,veterinary, etc.) and uses onN 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. DYe06No Does your business handle an acutely hazardous materlal? See definition on reverse side of this form. <br /> 04. ❑Yes P_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. 1 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 k�ppKE� Date: /� <br /> P ' t ame Title: 6E�E(L� nAygTj - <br /> X �` <br /> Signature <br /> F:IDEVSVCWIanning Appiicauon Foans\Use Perm){, (flavited i-M3) Page 6 of 9 <br />