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AqulN ry/� v <br /> COUNTY OF SAN JOAttUIN <br /> OFFICE OF EMERGENCY SERVICES RECEIVED <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 MAY -4 W <br /> Telephone(209)468-3962 SAN JOAQUIN COUNTY <br /> Hazardous Materials Division (209)468-3969IFFICE OF EMERGENCY SERVICER <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 its required. <br /> Business Name: <br /> Business Owner(s) Name: Ali ;el �1r1arZ t4mrl¢ �jt/GWTelephone: <br /> Business Address: ���/ys /f/ Ide- <br /> Mailing Address (if different from above): <br /> Nature of Business: '� /��Oprf Fire District: t✓flol91ir/ dam. <br /> Q1. ®Yes o Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> 1 definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2. )4Yes yffjlo Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br /> 11 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? 2- <br /> If <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> AA. 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 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. ❑Yes QtNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. fdYes ❑No Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> FA <br /> I 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. I <br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best <br /> of my knowledge. <br /> Owner or Authorized Agent: A/ <br /> X v!/G!✓�" `"� Date: �II /9 7 <br /> Print am <br /> X Title: <br /> Signature <br /> FADevSvOPlanning Application FormslBusiness License(Revised 08-30-06) Page 4 of 7 <br />