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`�n�rn"�,• COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> TelephoneJ209)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: Ary-oN FOTJTPMENT MIPAa <br /> Business Owner(s)Name: VIVALDO "VMLTER° AZElVEDO Telephone: 209- 606-2197 <br /> Business Address: WO W D10SSDALE ROAD I _ATHROP' CA 0449 <br /> Mailing Address (if different from above): p,0, Box 905 MANTECA, CA 95336 <br /> Nature of Business: AG EcnziT:ment Sales Fire District: Tracy Rural <br /> Q1. OYes M No Does your business handle a hazardous material In any quantity at any one time in the <br /> year? See the definition of hazardous material on the back of this form. If your answer is <br /> No;go to Question 4. <br /> j <br /> 02. OYes CA No Does your business handle a hazardous matedal,or a mixture containing a hazardous <br /> material In a quantity equal to or greater than 55 gallons,500 pounds,or 200cublc feet at <br /> 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 /> 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 /> >t <br /> OB. This business Is a Health care facility(doctor,dentist,veterinary,etc.)and uses only medical gases. <br /> f4:; ; <br /> OC. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. OYes t;LNo Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. OYes Callo 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 propertythat 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 of <br /> my knowledge. <br /> er or Authozed Age <br /> X Date: l0 aq <br /> Print Name. <br /> X L Title: ©t jNEY( <br /> Signatu <br />