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COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868E 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 andIor address in San Joa pin County is required. ...... <br /> Business ( <br /> Name: <br /> ,�� J �1 c <br /> Business Owner(s) <br /> Name: a Telephone: <br /> Business W `` bJ��i l <br /> Address: 7 t <br /> Mailing Address(if different from <br /> above): <br /> Nature of <br /> Business: f�A) Fire District: Lq-T;i p_z P <br /> Q1. []Yes XNo 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. ❑Yes )7No 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 9DAI medical <br /> gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. []Yes kNo Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> 0 <br /> 4. Yes ©No Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? <br /> 1 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 or At t �/�z�d Age <br /> X Date: <br /> Print Name <br /> - <br /> X Title: <br /> ature <br /> F/ApplicafionsForms&Handouts/PlanningApplications/Business License(Revised 02-24-15) <br /> Page 4 of 6 <br />