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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: ��� � � � o-s) <br /> Business Owners) p, <br /> Name: ��I�11�� � ,61 � Telephone: <br /> Business �\ � <br /> Address: ®4 + \y` <br /> Mailing Address(if different from <br /> above): <br /> Nature of <br /> Business: � ���-.1�.� Fire District: <br /> Q1. DRIes ❑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. MYes Flo 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 /> DA. 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 /> ❑B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses only medical <br /> gases, <br /> ❑C. This business operates a farm for purposes of cultivating the soll, raising,or harvesting an <br /> / agricultural or horticultural commodity. <br /> 03. []Yes LNo Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4, DYes M/0 Is 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 orAuthorize Agent; <br /> X t,QV,QQ -1au�3��--- Date;_ <br /> Print im <br /> amiX40 N <br /> at e <br />