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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> a ?i 2101 E. EarhartAvenue, Suite 3-- <br /> Stockton, California 95202 <br /> Telephone (209)953-6200 <br /> �rFORt'� 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: 4l — oVej �\J 1✓1 e, y <br /> Business Owner(s) Name: V 6 r n J "tib I E✓ r'h Telephone: b — <br /> Business Address: %-7b�l h F44-.�,�( .{- - <br /> Mailing Address (if different from above): <br /> Nature of Business: Fire District: W .:7 <br /> Q1. OYes *.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. OYesXNo 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 /> OB. This business is a health care facility(doctor,dentist,veterinary, etc.)and uses only medical gases. <br /> OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes laevo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes '*0 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. I <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 A <br /> X -4Q✓ n q er—� Date: LIQ/ 20 / I <br /> Mme <br /> X Title: <br /> �;1 gnature <br /> F:0EVSVCT1anning Appliw0on Farms\Site Approval.(Re iced 02-03-10) Page 6 of 9 <br />