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1 VV 0 or` 5-M <br /> Qa,N COUNTY OF SAN JOAQUIN AUG 2 2 2000 <br /> ° Q hoc OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> ROOM 610,COURTHOUSE DIRECTOR OF <br /> 222 BAST WEBER AVENUE EMERGENCY OPERATIONS <br /> STOCKTON,CALIFORNIA 95202 " <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 County iissrequired. <br /> W <br /> Business Name: iunaS /tt"/t�1 UMarkPf- <br /> (leMeM, . 'zuedleM. <br /> '!a A�DLL. - yca � `,, YeUr 2 Telephoned-z�� ��`5551 <br /> Business Owner(s)Name: <br /> Business Address: IN N nur/�/I50M6`d ���f �7/ <br /> Mailing Address(if different from above): T 0 �� « 406kAprU g5Z7 I/ �? <br /> Nature of Business: KP�l� �ne Fire District: / okelUI'1 le <br /> Q 1. *es 71NO Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> i 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 /> r�K 1D l� A <br /> If"Yes',how long have you handled these materials at your business? �— <br /> Il <br /> O Q S �plti410If "Yes",check any of the following conditions that applies to your business? <br /> \� <br /> VA. The hazardous materials handfed 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 o&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 [1?No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes i%No 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 /> XivNC/�I L. POLI Date slrz/L� <br /> Print Name ' �— <br /> X Title <br /> Signature (Rev 4/99) <br />