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r <br /> Ra�In. o� V cad` <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Q: <br /> ` 2101 E. Earhart Avenue, Suite 300 RECEIVED <br /> Stockton, California 95206 <br /> • .......... <br /> FO•RN`P• Telephone(209)953-6200 OCT — 2��0 <br /> FAX(209)953-6268 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY SAN JOAQUIN COUNTY <br /> OFFICE OF EMERGENCY SERVICES <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 County is required. <br /> Business Name: Wast R V rV WeSt ,Zn[- dba WRW, Tnr- <br /> Business Owner(s) Name: Mark W I he, Telephone: F>n?�-a40 IQ IG <br /> Business Address: 4554 5 Eldorado S r,SinctInn I CA q5201 <br /> Mailing Address(if different from above): 'PI)�57DX 633aA �J� <br /> ,Por+10nd, OR q-ia <br /> Nature of Business: rap— ems i��cS/c/i�„ Fire District: h <br /> r <br /> Q1. CYes 1KNo Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br /> of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2. CYes XNo Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br /> 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 /> CA. The hazardous materials handled by this business is contained solely in a consumer product, packaged <br /> 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 gases. <br /> CC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3. CYes )(No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. DYes)No 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 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 the <br /> 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-`C tt9 Date: ��o7,7//0 <br /> Print N <br /> X�dfy Title: <br /> L `i atur <br /> F:\DevSvc\Planning Application Forms\Business License(Revised 01-2510) Page 4 of 7 <br />