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3 : � L, L;'J V � <br /> ~4 , i3 k { <br /> Lee <br /> COUNTY OF SAN JOAQUIN <br /> Environmental Health Department l <br /> 1868 E Hazelton Avenue "! <br /> Stockton , California 95205 <br /> Telephone (209) 46 & 3420 g1VI ; : � . €� � INi ' . <br /> FAX (209) 468- 3433 - a <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 �} y <br /> Name : � �✓ l <br /> Business Owner(s) <br /> Name : T-0 <br /> nog ar Telephone : <br /> Business -� MR, <br /> Address : � � r � 1� / l� <br /> above) : <br /> Address (if different from ( n Den S+ V R1 D �rn � C <br /> above : G `� -( t `� <br /> Nature of <br /> Business : j,� � � �� �� <br /> Vn <br /> � Fire District : Df r <br /> &4 <br /> Q1 , ❑ Yeso 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 . ❑ 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 /> ❑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 pWI medical <br /> 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 %1No Does your business handle an acutely hazardous material ? See definition on reverse side of this <br /> %P <br /> form . <br /> Q4 . ❑ Yes 1P 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 Aut orized Agent :._ <br /> X .) I� C 4*CICA. � � � 01 Date : <br /> P ' <br /> X _ __:� .°. Title : <br /> Signature <br /> F/Applications Forms&Hand outs/PlanningApplications/Business License (Revised 02-24- 15) <br /> Page 4 of 6 <br />