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.JUL <br /> et. — COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMF-RGENCY SERVICES RONALD R.■ALDWIN <br /> .rc s ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> • STOCKTON, CALIFORNIA 95202 <br /> baw TELEPHONE(209)463-7962 <br /> HAZARDOUS MATERIALS DIVISION(209)4611-3969 <br /> HAZARDOUS MATERIALS SURVEY FORM <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: <br /> Business Owners)Name: <br /> O N TACiT` :r�T PcT1C f� Telephone: �O}�— 3 Z <br /> Business Address: _� c-rj'Zr7iV �K17IJAM.,,- '��t'k 7'[� r <br /> Mailing Address(if different from above): <br /> Nature of Business: C-�,j \17!,,_j=� Fire District _ <br /> QI. _Yes flNo Dues 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 /> 02 ']Yes ONO Does your business handle a hazardous matenal,or a mixture containing a hazardous matenal,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 it your business? . <br /> If "Ycs".check any of the following conditions that applies to your business'? <br /> fl 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 /> O B. This business is a health care facility(doctor,dentist.veterinary,etc.)and uses only medical gases. <br /> D C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. - <br /> Q3. uYes CNo Docs your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes ONO 1s 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 undcratand my requirements under Chapter 6.95 of the California Health and Saferf <br /> Code. I understand that if 1 awn a facility or property that is used by tenants, that it is my responsibility to notify the tenanes of <br /> the rcgwrements which must be met pnor 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 W IA`t,-v art 1 �,, Date 121 3 <br /> Print Name <br /> S-- Title <br /> Signature (Rcv IGNO <br /> ZT ' !1J - - <br />