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COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 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 San Joaquin County is required. <br /> Business <br /> Name: 11M ci,o YL. 41,K4-i.I fl,°.DDxaz <br /> Business Owner(s) <br /> Name: WM12)9,it , ftAN-rMkNA61Ep Telephone: 00� ZZl =(0 <br /> Business <br /> Address: :?JV WD 5MLVsf-?5A"TPr t2OCrD.1't� CA Gj`�-�✓p�' <br /> Mailing Address (if different from <br /> above): <br /> Nature of <br /> Business: Fire District: eAr( OfTRACq <br /> Q1. ZYes ❑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. �es ❑No 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? Wp__ ' <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> ❑A. 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 /> El B, This business is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical <br /> gases. <br /> El C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. &' es ❑No Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> Q4. ❑Yes Omo�Ios 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. <br /> I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge. <br /> Owner pr Authorized A ent: <br /> X D Date: "DELbSEY� l 2015' <br /> Print Nam PLANT i1MAN A<ISIZ� <br /> X Title: <br /> Signatur <br /> F/AppllcationsForms&Handouts/PlanningApplications/Business License(Revised 02-24-15) <br /> Page 4 of 6 <br />