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J CdUNTY'OF SAN J6AQ <br /> PurH OFFICE OF EMERGENCY SERVICES <br /> Room f 1 U, Coriruse :. <br /> East wk6eir_ e <br /> 5to tarn, o g <br /> �cti 2Q� <br /> rk25 'fel �nef3Q � '" <br /> Hazardo is tertals piton( E )A6&-39fi5. <br /> <-i4ZARDC I] AAT€RIAt_S:DIrdL0SUAE SURVEY: M <br /> Please read the in#ormabon on thv.e reverse side before Cmpletrng 1.this survey form A separate survey for each.tuslness <br /> name.andW address in Sart Joaquin County rs,Fequir : <br /> Business Marne: .. <br /> tilt t <br /> 'Business Ovuner(s)Name: Tel <br /> ) <br /> Business Address: ' i Chi vVt O <br /> Mailing Address(if different from above): <br /> r <br /> Nature of.Business: n Fire District:. <br /> Q1. 17Yes. Jo Does your business handle a'hazardous material in any quantity at anyone time in the.year? Seethe <br /> r! definition of hazardous material on the back of this form. If your answer is No."go to Question 4. <br /> 02. ©Yes 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 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 /> ! 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 /> OB. This business is a health care facility(doctor, dentist,veterinary, etc.)and uses only 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. OYes ONo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> 04. OYesNo Is your business within 1,000 Feet of the outer boundary of a school (grades K-12)? <br /> E 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 penally 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 /> i X � G, vb rJ �� Date: G - <br /> Print Name <br /> Title: <br /> Signature <br /> l <br /> FVEVSMPIanning Applicalion Forms%ite Approval.(Revised 4-3-03) Page 6 of 9 <br />