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03/08%1999 09:30 2099430415 LESWSKY/DONALDSDN D PAGE 02 <br /> S A 99 - 26 <br /> N <br /> COUNTY OF SAN JOAQUIN sALowtN <br /> s,a OFFICE OF E v1ERGENCY SERVICES a� <br /> f'!a ROOM 610,COURTHOUSE COORDnNn7ox <br /> 222 EAST WEBER AVENUE <br /> STOCKTON.CALIFORNIA 45202 <br /> TELEPHONE(104)469.3962 <br /> HAZARDOUS MATERIALS DIVISION(209)461-3969 <br /> HAZARDOUS MATERIALS SURVEY FORM <br /> Please read the information on the reverse side before completing this survey form' A separate survey for each business name <br /> and/or address in San Joaquin County is required. J <br /> Business Names univergity <br /> _ JX� <br /> BLL9inecs Owner(9)Name: 1;t11D'Ver51tV hl { 4c-hml S _ Telephone: — <br /> Business Address: =0088 G. 99 Stoektcr. a. 9e 12 <br /> Mailing Address(if different from above): 1564 Laurel 5t., San Carlos Ca. 94070 X <br /> Nature of Business,..,[. Chaz*_er Seh <br /> 1 K-6 Fin District: Mcrada X <br /> Ql. ❑ .Yes kAo Doe,your business handle a hazardous material In any quantity at any one time in the year^ Seethe <br /> definition of hazardous matenal on the back of this form. If your answer is"No"-90 to Question 4. <br /> Q2. OYes 16No Does your business handle a hazardous material.or a mixture comaining a hazardous material,in a <br /> quantity equal to or grater than 55 gallons,500 pounds,or 200 cubic feet at any One tuna 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 /> M A. The hazardous materials handled by this business is contained solely in a consumer produll packaged for <br /> direct diseibution to, and use by,the general public. <br /> :113. This business is a health care facility(doctor,dentist,veterinary,etcJ and uses enby 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. CYes RNb Docs your business handle an Acutely Hazardous Marenitl^. See definiuo on reverse side of this form. <br /> ,�.e" of a school(grades K-12)? <br /> -� Q4. alit ca �1•I o Is Your business within t,Olb feet of the Darer boundary gra <br /> e California Health and Safety 6.95 of th <br /> 1 have read the information on this form and understand my requirements under Chapter' � nants of <br /> Code. I understand that if I own a facility or property that is used by tenants,that it is my responsibili ty to notify i'declare he teto under the <br /> the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operaticns <br /> penalty of perjury that the ir.fetration provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent. `_ 3/ <br /> '( X JIs agrl4az U C t'\ S r\G 1 Date �^ ,^ <br /> Print Name C. �C.7-v'v` <br /> Tile <br /> X dtcv 1 I <br /> t <br /> Signature L <br />