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COUNTY OF SAN JOAQUIN <br /> ' f OFFICE OF EMERGENCY SERVICES <br /> rte: i <br /> 2101 E. Earhart Avenue, Sul#e 3— <br /> Stockton, California 95202 <br /> Telephone (209) 953-6200 <br /> 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: V C.c_ <br /> 1..J <br /> Business Owner(s)Name: <br /> Business Address: Telephone: Z �9�-,` Z- 33 <br /> Mailing Address (if different from above): <br /> Nature of Business: <br /> Fire District: <br /> Q1. Q�es ONo Does Your business handle a hazardous material in an <br /> _ definition of hazardous material on the back of this form,quantity <br /> your answerone is NO.'go toe inaQuestion 4. the <br /> 02. a,1Yes <br /> Neo your business handle a Nazar <br /> dous material, or a xture <br /> material in a <br /> quantity equal to or greater than 55 gallons, 500 Pounds,{or 200 ub ci ning feet ataazardous 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 /> DA. 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 /> DB. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. <br /> 96. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. [Wes DNo Does your business handle an acutel hazardous material? See definition on reverse side of this form. <br /> Q4. ©Yes 941 <br /> 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 ism res <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. 1 <br /> declare under the penalty of Y responsibility to notify the <br /> p ty perjury that the informs#ion provided on this disclosure survey is true and accurate to the best <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> X a C c 't g <br /> Print Name Date: Zo L l <br /> X '����4 <br /> Signature Title:- <br /> FADEVSVCIPianning APPIPC8600 FormsWse Pe"iL(RevL%ed 02-03-10f Page 6 of 9 <br />