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RECEIVED <br /> amw C15 LF9 20 <br /> q, � JHN JUHUUI <br /> COUNTY OF SAN JOAQUIN CFRCECFEMERBENOw Ng"CE8 <br /> 1 PgU�r! <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> e -+ ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> • r.. STOCKTON, CALIFORNIA 95202 <br /> 1 Gi d0'R N�' <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 name <br /> and/or address in San Joaquin <br /> County <br /> is required. <br /> Business Name: W D 11 1 1`p�Vy�//��I lam- A <br /> Business Owner(s)NNaame: I�`A��`-4ill_.LFIVW��C.N�L�7 Telephone: "Ll ll/)����V�V <br /> Business Address: CtD�' i �T(_�dl_ <br /> Mailing Address(if different <br /> from above): Y <br /> Nature of Business: V WU v cl) Fire District: <br /> Q 1. ❑Yes 1fNO 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. Oyes P0 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 200 cubic 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 packaged for <br /> 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. 0Yes 11Vo Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. OYes 214o 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 Safety <br /> Code. 1 understand that if I own a facility or property that is used by tenants, that it is my responsibility to notify the tenants of <br /> the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> X I Date J �� <br /> Print Name <br /> X Title T <br /> Signature ,Vv 10/96) <br />