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Op4U'�~ <br /> c <br /> S�/FUpN` <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610,Courthouse <br /> 222 East Weber Avenue <br /> Stockton,California 95202 <br /> 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 yJooaquii�n County is required. <br /> Business Name: 801a- <br /> Business <br /> Business Owner(s)Name:_ Telephone: 2 o.9 4-77—6n <br /> Business Address: 7 39 3 L . S T, ".Sr 14-1 131 �a�y <br /> Mailing Address(if different from above): P. (S,,- 5-7 Mo L'J,. (a 9 p <br /> 535 0 <br /> Nature of Business: Fire District: 7""'1 Aur-1 <br /> Q1. 3,kyes ❑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 /> Q2. C(Yes ❑No Does your business handle a hazardous material,or a mixture containing a hazardous <br /> material in a quantity equal to or greater than 55 gallons,500 pounds,or 200cubic feet at <br /> any one time in the year? <br /> If"Yes,"how long have you handled these materials at your business? 50 + <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> YIA. 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 /> 11 B. This business is a health care 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 /> Q3. ❑Yes .0No Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. ❑Yes 91No Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? <br /> 1 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 of <br /> my knowledge. <br /> Owner or Authorized Agent:/J <br /> X pa(� ,,'&- Date: _0401 <br /> X 0Pr n4 n <br /> ✓k Title: <br /> gnature <br />