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r.' •z� <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> Telephone,(209)468-3962 <br /> Hazardous Materials Division (209)468-3969 <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 Name: <br /> /� /��o Telephone: 887-�a� <br /> �k>' Owner(s) Name:/� <br /> p4� Address: ! <br /> Mailing Address (if different from above): _f <br /> Fire District:Z'hd, 5 <br /> Nature of Business: <br /> Q1, ❑Yes �No Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on the back of this form. If your answer is <br /> No,"go to Question 4. 0 7L-"rD�il�/'� <br /> zardous <br /> xture <br /> Q2, ❑Yes ° material quantity al in a quanty equal to or greater than pounds,orghazardous <br /> Does your business 200cubicfeet at <br /> any one time in the year? AJo 7L <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 /> ❑A. 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 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 Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. /UG /— _/1-P,041 ew'4, �-_ <br /> Q4. ❑Yes �[�lo Is your business within 1,000 feet of the outer boundary of a school(gr des K-1 2)? <br /> f `� <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the Calif rnia 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 of <br /> my knowledge. <br /> Owner or Authorized Agent: <br /> X Ni d �' "`'� Date: c+(,— '0 3 <br /> /� Print Nam ,r <br /> X "� i'li �\ Title: QLCI L�L�✓ <br /> Signature <br />