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` • l�'�iJ c.04 <br /> 2 Z <br /> N , K <br /> K�(F UAB <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> 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 Name: tLL '-(� TXVC((C ( JG— <br /> Business Owner(s) Name:TUA , 16%1'04 4 YN 6 LI6 Telephone: qL1 B �L C, <br /> 9 <br /> Business Address33q3) �� i0 IJ W'TOr� <br /> Mailing Address(if different from above): O 1�OX 115�3 O 3 - f)60 C4 qS`U <br /> Nature of Buu�siness:,,� -Filir K( ,-9 G Fire District LL),ti-'�Z I-O c' <br /> Q1. 13Yes OAtlo Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on the back of this form. If your answer is <br /> No,"go to Question 4. <br /> Q2. MYes ❑ No Does your business handle a hazardous material, or a mixture containing a hazardous <br /> material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feel at <br /> any one time in the year? <br /> If"Yes,"how long have you handled these materials at your business? 1Efi� r2O� "7 <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> 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. OYes Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. OYes E,14o Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? <br /> 1 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 of <br /> my knowledge. <br /> Owner or Authoo''�d Agent: <br /> X 1,Jz:-jj -/ S Date: <br /> Printam <br /> X �� Title: / f <br /> Sigafflure <br /> 1 r�i rr..� ,R✓f✓✓��5� <br /> 1I,�[, j�/I T�e•.2n> IVL � .Tf6e Stint cT 3973 ( Nc <br /> /UD PtvW ✓(rGCGS[ cJ �C J( rel A M�1A �� � <br />