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I►UUN I Y Ul- JAN JU/-w c IN <br /> OFFICE OF EMERGENCY SERVICES <br /> RVVI l I V I V, CoUI ll IVl}JC <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> C4L�FpR�`P 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 Joaquin County is required. <br /> Business nh ���� i i �i�i"i� i.ii iA� <br /> UJII IGJJ 1 YQI I IG. p /, <br /> Business Owner(s) Name: RIC Yl 11 KC Telephone: (\,��L\,' <br /> Mailing Address (if different from above): Y)5-3?) K H1,1:1 0`1 —�Qj l n py OA C 1,52A <br /> NafhirP of RlicinPz i�k Lu, ` <br /> s: l k LSI l Fire District-. �,a A r 4 tic- <br /> Q1. s ❑No 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 es No 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? L Nt(l h' <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> ❑A. 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 /> ❑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.'*es ❑No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes VNo 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 rrodP. I iiinriorctnnri that if 1 o�ln a facility or prone ,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 surJcy is true and accurate to the best <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> X Ken _��i l'l fl kt_ Date: '_3-_I L�, �' 3 <br /> [[/R/tint Kame/1 <br /> X flnrtt.w �.���, Title: L'Lel:OC Y <br /> Signature <br /> \DEVSVC\Planning Application Forms\Site Approval.(Revised 13-03) Page 6 of 9 <br />