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Irv" <br /> a <br /> 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: , C <br /> Business Owner(s) I (, <br /> Name: 1Cn1I,�._ � - VI r Telephone: <br /> Business <br /> Address: Tma C <br /> Mailing Address (if differs t from <br /> above): <br /> Nature of <br /> Business: TS'UC(� - 1, Fire District: YVYU aL� <br /> Q1. ihyes ONo Does your bu iness 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. AYes ONo Does your buiness handle a hazardous material, or a mixture containing a hazardous material In a <br /> quantity equa to or greater than 55 gallons, 500 pounds,or 200cubic feet at any one time In the year? <br /> If"Yes,"how I ng have you handled these materials at your business?-W6 W ! L. <br /> If"Yes,"chec any of the following conditions that applies to your business. <br /> OA. The ha ardous materials handled by this business is contained solely in a consumer product, <br /> packagE d for direct distribution to, and use by, the general public. <br /> OB. This WE iness Is a health care facility(doctor, dentist, veterinary, etc.) and uses pRly medical <br /> 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. ❑Yes ONo Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. []Yes , No, Is your businec,s within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 have read the information on W5 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 whicti must be met prior to issuance of a Certificate of Occupancy or beginning of operations. <br /> I declare under the penalty of per,ury that the Information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge. <br /> Owner or Authorized Agent'(,, <br /> gent: <br /> X ( Date: if <br /> Print Name a-� <br /> XdfNeW Title: <br /> Signature <br /> F/ApplicationsForms&Handouts/Planning pplications/Business License(Revised 02-24-15) <br /> Page 4 of 6 <br />