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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 : a %f\ o il O 'i c5 c' ( )'UIttF � on ) - <br /> Business Owner(s ) <br /> Name : Ci` Telephone :P ('iCtt� p Peib`-( � <br /> Business <br /> Address: u( , 7voy LGl ►'t (? � udi ( ('t - - - <br /> Mailing Address ( if different from <br /> above ) : _ <br /> Nature of <br /> Business : (' UM j U 'i� F'�� 1 �� S.) f' 4�' � ��_� Fire District : <br /> Q1 . ® Yes ❑ No Does your business handle a hazardous material in any quantity at anyone time in the year? Seethe <br /> definition of hazardous material on the back of this form . If your answer is No , go to Question 4 . <br /> 02 , ❑ Yes 15No 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 /> ❑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 gq11 medical <br /> gases . <br /> 11 C , This business operates a farm for purposes of cultivating the soil , raising , or harvesting an <br /> agricultural or horticultural commodity . <br /> Q3 . ❑ Yes [9No Does your business handle an acutely hazardous material ? See definition on reverse side of this <br /> form . <br /> Q4 . ❑ Yes I.RNo Is your business within 1 , 000 feet of the outer boundary of a school (grades K- 12 )? <br /> 1 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 or Authorized Agent : <br /> X ) 0� ( ( Cif' (t ,1y Date : <br /> Pg Name <br /> X Tiile : i U <br /> Signature <br />