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COUNTY OF SAN J(,.. UIN <br /> P4 •IM. <br /> • �•�:•�� OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> ` 222 East Weber Avenue <br /> Stockton, California 95202 <br /> i;FokNa 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: Q -Re50 y" I t <br /> Business Owner(s) Name: Telephone:C7o <br /> Business Address: 0 U —C 01r 1 i •` <br /> Mailing Address (if different from above): J <br /> Nature of Business: \Ul,�f ��"��5 Vn( 1 U 1 IpL'� fire District: C"(],(�� <br /> r <br /> Q1. dyes DNo 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 /> DIY1IVe <br /> Q2. <br /> Yes 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 /> DA. 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 /> DB. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. <br /> DC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. DYes EfNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. DYes HNo 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 /> OwnS natu Owner or Authorized A t: ! <br /> X O L Date: — I J 0 c5 <br /> ne m �� � <br /> X Title: YQ(1 "(,L.11(71/��OOIf(Y�llrtQ sol✓ <br /> F 0EVSVCWIanning Application FormWl PennR(Re ised 603-04) Page 6 of 9 <br />