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PA— 1 150 <br /> COUNTY OF SAN JOAQUIN <br /> EmAronmental health 139"ftwnt <br /> 1868 E Hazelton Avenue <br /> Stockton, Caltfbmia 95205 <br /> Telephone(209)468-3420 <br /> FAX(209)468-3433 <br /> Website:www.sjgov.org/ehd <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 Son Joaquin County is required. <br /> Business Name: -St. 1j,� C GL K QC Gj <br /> nep <br /> Bushes Owner( )3Name: <br /> �- -r �'-� e�C4 i,f Telephone: )0q <br /> Business Address: P-0-4 V-- <br /> Mail"Address(if different from above): S� 0 <br /> SiSIocl< At <br /> Nature of Buslnen: /2 - Fire District <br /> Q1. OYes Ckb 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. E[Yes I(No Does your business handle a hazardous material,or a mature containing a hazardous material in a <br /> quantity equal to or greater than 55 galk)ns,600 pounds,or 200cubk:feet at any one time In the year? <br /> if'Yes."how"have you handled these materials at your business?— <br /> If'Yes,"check any of the following condfflons that applies to your business. <br /> 13A- The hazardous materials handled by this business is oontalned solely in a ounsumw product, <br /> packaged for dked dkrtnbufion to,and use by,the general public. <br /> OB. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses only medical gages. <br /> EIC. This busirmss operates a farm for purposes of cuffiv8ft the sioll,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. 13Yes gNo Does your business handle an 11cutely b=rdom matww—? See definition an reverse side Of this form. <br /> Q4. ElYes 11ANo 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 understard my requirements under Chapter 6.95 of the Callfomta Health and <br /> Safety Code. I understand that N I own a Willy or property that Is used by tenants,that it is my resporaWity to notify the <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operatiws. 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 Agent <br /> X_-Lct, 1�4e-,/,e MV Date- <br /> P'641�e <br /> x - <br /> Signature <br />