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p(tOM a - (SHT>JUL < 2009 11 :23/97. 11 t8/Mo.7613909986 P 6 <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue, Suite 3-- <br /> e: K 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: S t( pw-f— V� mi4 t, <br /> Business Owner(s)Name: if, - Telephone: <br /> Zflcy <br /> Business Address: 5pc � IF, A CA `3452-42- <br /> Mailing <br /> 52-42Mailing 3�-1l <br /> Address (if different from above): \ 'f� <br /> Nature of Business: k"6h11AUCS V.(I Fire District: DC-f - <br /> Q1. []YesLt�lo Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> r' ` definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2. DYes li�6o 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 /> OA. 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 /> 11 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 /> 03. ❑Yes�No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes )�No 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 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. 1 <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 /> D Dl - o 9 <br /> X �� id Y,0!/L�� Date: � — <br /> 'Print <br /> i� Title: <br /> Signature <br /> F\DEVSVC\Plannlnp Application Forms\Use Permit.(Revised 05-11-09) Page 6 of 9 <br />