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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> y: ROOM 610,COURTHOUSE DIRECTOR OF <br /> 222 EAST WEBER AVENUE EMERGENCY OPERATIONS <br /> c .. STOCKTON,CALIFORNIA 95202 RECEIVED <br /> {4jcdnN TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY OCT 2 9 2003 <br /> JNTY <br /> Please read the information on the reverse side before completing this survey form. A separate survey f m G <br /> ERM <br /> and/or address in San Joaquin County is required. <br /> Business Name: !L. Ihjq o/U LJRpk-l/r_� / / <br /> Business Owner(s)Name: L Q o-T -Tr';' � t d f lV Telephone: Leq ffr 7?Z y/ <br /> Business Address: i`Z f yS N DP Y 1 ICC: --- — <br /> Mailing Address(if different from above): " �t/ �'t L �rv1LD/y 5'Szc� <br /> Nature of Business: �Oe.4 ' Ott%Ne9' ' �ryx�Fc`I � Fire District: LU04G�"td9�- <br /> Q 1. ❑Yes tNo Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> /v 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 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 pply medical gases. <br /> ❑ C. This business operaf:es a farm taising,arbarvesti tgart <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes ONO Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes 0 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. I 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 II��tDf'I^� dr'` N Date // <br /> nt e <br /> X j c Title (!yw'r� <br /> i ature (Rev 4/99) <br />