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COUNTY OF SAN JOAQUI <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 anis%r address in San Joaquin County is required. <br /> Business <br /> Name: <br /> Business Owne s) <br /> Name: C Telephone: , q,. . -40� (� <br /> Business <br /> Address: li-StWyq 67-31 <br /> Mailing Address (if different from p� <br /> above): 'O• l <br /> Nature of <br /> Business: Fire District: <br /> Q1. DYes 9No 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. DYes •�f! to 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, 5.00 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 /> DB. This business is a health care facility(doctor, dentist,veterinary, etc.)and uses only medical <br /> gases. <br /> DC. This business operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. DYeso Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. Wes ONo Is your business within 1,000 feet of the outer boundary of a school(grades K-1 2)? <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 /> 1 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 /> Ow er qr Authorized gent: <br /> X xor\ A4'e sar— :!A®Xkbs <br /> ® <br /> rinte <br /> X Title: <br /> Signature <br /> Mi.ligtionsForrns&Handouts/PlanningApplications/Business License(Revised 02-2415) <br /> Page 4 of 6 <br />