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COUNTY OF SAN J UIN <br /> Aqu�a• <br /> a fi OFFICE_ OF EMERGENCY SERVICES ., <br /> `Room m�10," outhouse t <br /> 222 East Weber Aveh.up. <br /> V7 k <br /> Stockton, Calmfomla 95202 <br /> �2fJ9) 8 � a <br /> > `. tiWo"bugl §tdQ0DK is `h <br /> HAZ4RDOU$'MAEF�IALS DISCt_t7SURB SURVEY <br /> Y i4a �' ' ,__y} y.r` r ° y g' +7 ria s <br /> Please:read the rnformatlon#sn this reverse side before`completing,this survey form: A separa#e°survey;:or each bt�slness <br /> name and/or>address mn San'Joaquin Cotinty is required. <br /> Business Name: c -x <br /> i <br /> Business 6vner(s).Name: MZ, _ +moi " M2 Telephone: V. 6 X-33S,Z <br /> Business Address: 12- 2.0 3 1\1,- <br /> Mailing Address(if differenf:from above): b &o�,c (dad oc o An'Z46.0L <br /> Nature of Business: �`!W � ��o M 9-rAa Qt of Distri <br /> 5o..aJ�ce.� Fire <br /> ct:' <br /> Q1. 4'es ©No Does your.business handle a hazardous materiai'in any quantity at'ariy:orfe tune in the yea#? S'e'e the' <br /> definition of ha26rdout- moterial on the back of this form. If your answer is No,"go to Question 4-._ <br /> Q2. b3�'es 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 /> The hazardous materials handled by�hls business ms oontatned,solely in a consumer product,.. <br /> packaged for direct distribution to, and use by,the general public. <br /> 0.B. This business is a health care facility(doctor, dentist,veterinary, etc.)and uses 2UI medical gases. <br /> ©C. this business operates:afarm.for.purposes.of cultivating the soil, raising, or harvesting an. <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes '6lo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes 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'ifl I own a facility or property'that is used-i ytenants; that itis my resp6ni ib6iliiy to notify the <br /> tenants of the requirements which must beTmet prior to issuance ofla Certificate of Occupancy&beginning of operations. <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 i D L_AL x) Date: <br /> Pr' .�- <br /> X Title: <br /> ignature <br /> F:0EVSVC\PIanning Application FormslUse Permit(Revised 1-2-03) Page 6 of 9 <br />