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COUNTY OF SAN JOA(JUfN <br />OFFICE OF EMERGENCY SERVICES <br />'y Room 610, Courthouse <br />222 East Weber Avenue <br />Stockton, California 95202 <br />-elephone (209) 468-3962 <br />R Hazard6US Mat.erials Division (20!5) 468-3969 <br />HAZARD Ut MATE <br />RIALS DISCLOSURE SURVEY <br />Please read ttte inforrriation on the'teverse side be#dre 60mpletingthis survey form: A separate survey fo :each business <br />name and/or`address m San Joaquin Coun'' required. <br />Business Name: <br />Business.Qwner(s) Name: <br />Business Address: <br />--`.1u:-� �(i� Y,Gf.L'1/1 Telephone:-3-c.fv <br />42 C> <br />Kr <br />Mailing Address (if different from above): , <br />Nature of Business:_'— <br />Fire District: <br />Q1. OYes i No Does your business handle a hazardous material in any quantity at any one time in the ear? <br />See the <br />t definition of hazardous material on the back of this form. If your answer is No," go to Question 4. <br />Q2. ❑Yes �No 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 only medical gases. <br />13C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br />agricultural or horticultural commodity. <br />Q3. DYes 4No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br />Q4. t L� es ONO 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. I <br />declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best <br />of my knowledge_ <br />Owner or Authorized Age <br />x----J� r r r -- Date: <br />Name <br />X-- _ Title:�_1�—�_� <br />Signature <br />F:ITFVSVCT1annin9 APWakn Formg$ SOP Approval. (Revised 1-3-03) Page 6 of 9 <br />