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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue, Suite 3— <br /> Stockton, California 95202 <br /> Telephone (209)953-6200 <br /> i;aaaa Fax(209) 953-6268 <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: .4worei Alun Lp• //pr, <br /> Business Owner(s)Name:Vtm^t litvo � 14. &vA Telephone: �JJI/• 4734" <br /> t I1:Avie 1N/ yti <br /> Business Address: !2�✓�{ ,d, �,sibf.s4 <br /> I �y , =04AA01 G.f 9�i2/y <br /> Mailing Address(if different from above): "We <br /> Nature of Business: 'AAkAWAS Fire District: WW PA//O/ AVA44 <br /> 01. EdYes ONo 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 /> Q2. WYes 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? -074W& ZA'$ <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 fam(for purposes of cultivating the soil, raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. )Yes ONo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes Rfib 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 /> Owner or Authorized Agent: <br /> X ZlaeaL, 464(lf Date: <br /> Print Name <br /> x Title: evv�R <br /> Signatudeu <br /> # u?d 4JA4 wlrxa4stJ �CStrsfo�rJ wr�lt OEs— nes', Q» 1-D. t3413� ,} <br /> ry .ria uw .xeMcf/ /8"Awlo r -f",f4, L /�lie/a(� fo fLar�7.t1 wr/4w/s <br /> F?DEVSVCFWnn i;Application Fo m%Site Appm 1.(Revised 024.410) Page 6.of 9 <br />