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MAY -22-1996 12:03 OTOCKTON PEPh1IT CEP•1TEP 2019+937+0093 P.01 <br />MR! COT N SAN JOAQtiIN <br />OFFTCT <br />, iENCY SERVICES RONALD E. BALDWIN <br />taj T THAI, SF COORDINATOR <br />lz-AV [) <br />:)RNIBA9�RECEIVED <br />-{,'p •� �`�/ ?o; <br />=~ aR�� MAY 2 81996 <br />Har <br />ENVIRONMENTAL HEALTH <br />Please read the Hazardous Materials Inform! PERM % aRMU99C form for <br />each husiness name and/or address in San Jo. <br />B U `: i n � S5 :� a rt] e . � � !� t d"✓L C..e -t <br />Bustness Qwnerw '_Name: J kc1-ce_.(%crr —C • ___F'hnne. <br />Facility :address: 0�^`^^�V- L+� <br />11atlr.k Address. --f t � <br />sc of Business: _COIF ��� \ .� 1 -<re L)istric;: Jiz�Ck4tox t-�� �t <br />Q l �Y'es ❑ No Does your business handle a hazardous matenal'' Rea hack�sa�. if you answered "No" to Question 1, <br />go to Question d <br />Q2 Yes J No Does your business, handle a hazardous o-'ater a ,1T i ro--irc tiCJl1taining a ha7ardous material in a <br />quantity equal to or greater than 55 gallons, 5(ju pulmo:_ ,ir -JQ cubic feet at any one time? <br />If you answered "No" to Question 2..o to Quzztion 4 <br />If you answered "Yes" to Question 2, do any 01 !hc tv�!lowin,e statements apply to your business? Read <br />�+"1y-b-lsll��• <br />*A. The hazardous materials handled by tius business is contained suicl_v in .a Consumer product packaged for <br />dircc( distribution to. and use by, t'nc v,nor-al public, <br />❑ B, This husiness operates a health care facility 0.e , doctor, dentist. veterinary... ) and uses only inedical <br />gases_ <br />❑ C- This business operates a farm for purposes or cultivating the soil, raising, or harvesting; an <br />agricultural or horticultural conunoditv. <br />03 -J Yes 4; -No This business or building occupant handles an Acutely Hazardous Mat.enal'' Read <br />Q4. ❑ Yer:eg No This facility or modified facility will be within 1A K) feet of the outer boundary of a school (grades <br />K-12}. <br />I have read the Hazardous Materials Information Guide and understand my requirements under Chapter 6.95 of the California Health <br />and Safety Code. I understand that if the building docs not currently have a tenant, that it is my responsibility to notify the <br />occupant of the requirements which must be met prior to issuance of a Certificate of Occupan(ly 1 declare under the penalty of <br />perjury that this disclosure survey/exemption it nue and accurate to the best of my knowledge. <br />Owner or Authorized Agent: <br />Title OQC�c ep(i(OL� Z - <br />Print <br />R <br />Signatrkrr <br />Rev: ]f46 <br />Ww , <br />