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0 EASE P ZMD- TYPE ., <br />Q1. Please provide a separate survey -for each business name and address in San Joaquin. <br />County: <br />a. Business Name: >✓ L 5 Phone: ­ <br />b. Mailing Address: ` -Sw viG-Tb1Z Rb <br />j..t�Di CA l�aQO <br />c. Facility Address: ago RD <br />d. Contact Name: _C <br />e. Nature of Business: <br />f. Proposed Project: _ <br />Q2. Will the owner, applicant or future building occupant handle a hazardous material? <br />(Includes gasoline, oil, propane, oxygen, acetylene, ammonia, chlorine, pesticides, <br />Yes 0 No <br />Q3. Will the owner, applicant or future building occupant handle an Acutely Hazardous Material`' <br />(List of Acutely Hazardous Materials available at the Planning Department) <br />= Yes CZ No <br />Q4. Will the proposed building or modified facility be within 1,000 feet of the outer bound: ry of <br />a school (grades K - 12)? <br />Yes No <br />I have read the Hazardous Materials Information Guide (on back page) and understand my <br />requirements under Chapter 6.95 of the California Health and Safety Code Sections 25505, <br />25533, and 25534. I understand that if the building does not currently have a tenant, that it is <br />my responsibility to notify the occupant of the requirements which must be met prior to issu- <br />ance of a Certificate of Occupancy. <br />O,A,ner or Authorized Agent: (Print) ` \ �" <br />Date: 4 -i(0 --9i v (Signature <br />(Office Use Only) <br />1. Sen Joaquin Rir Pollution Control District <br />1601 East Hazelton Street <br />Stockton, CR 95205 <br />(209)468-3470 <br />2. San Joaquin. -County CIS <br />222 East Weber Ruenue, <br />Room 610 <br />Stockton, CR 95202 <br />(20 9 )944-21 16 <br />Ili <br />� Dept <br />F11eT# <br />JOAQUIN COUNT'. <br />` E RGENCY�SEVICES <br />TERIALS-DISCLOSURE-SUR VEY <br />0 EASE P ZMD- TYPE ., <br />Q1. Please provide a separate survey -for each business name and address in San Joaquin. <br />County: <br />a. Business Name: >✓ L 5 Phone: ­ <br />b. Mailing Address: ` -Sw viG-Tb1Z Rb <br />j..t�Di CA l�aQO <br />c. Facility Address: ago RD <br />d. Contact Name: _C <br />e. Nature of Business: <br />f. Proposed Project: _ <br />Q2. Will the owner, applicant or future building occupant handle a hazardous material? <br />(Includes gasoline, oil, propane, oxygen, acetylene, ammonia, chlorine, pesticides, <br />Yes 0 No <br />Q3. Will the owner, applicant or future building occupant handle an Acutely Hazardous Material`' <br />(List of Acutely Hazardous Materials available at the Planning Department) <br />= Yes CZ No <br />Q4. Will the proposed building or modified facility be within 1,000 feet of the outer bound: ry of <br />a school (grades K - 12)? <br />Yes No <br />I have read the Hazardous Materials Information Guide (on back page) and understand my <br />requirements under Chapter 6.95 of the California Health and Safety Code Sections 25505, <br />25533, and 25534. I understand that if the building does not currently have a tenant, that it is <br />my responsibility to notify the occupant of the requirements which must be met prior to issu- <br />ance of a Certificate of Occupancy. <br />O,A,ner or Authorized Agent: (Print) ` \ �" <br />Date: 4 -i(0 --9i v (Signature <br />(Office Use Only) <br />1. Sen Joaquin Rir Pollution Control District <br />1601 East Hazelton Street <br />Stockton, CR 95205 <br />(209)468-3470 <br />2. San Joaquin. -County CIS <br />222 East Weber Ruenue, <br />Room 610 <br />Stockton, CR 95202 <br />(20 9 )944-21 16 <br />Ili <br />