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V.< <br /> COUNTY OF SAN JOAQUINa .oma OFFICE OF EMERGENCY SERVICES RONALD Ii BALDWIN <br /> r.' s <br /> ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> • .C; STOCKTON,CALIFORNIA 95202 RECEIVED C^C Iv <br /> 7ELEPHONE(209)468-3962 C D <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 JR <br /> _ 2 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> OFFICE OF EMERGENCUUIN Y SERVICE: <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: �D,4n//4 WAP <br /> Business Owner(s)Name: 7-�10-,eA nju jp Telephone: 2f)9 <br /> Business Address: tri 6,^ /-4d.bffS7.P AL 0(24 <br /> Mailing Address(if different from above): <AAyL= <br /> Nature of Business: <br /> /// ©CAH I::4-4, 4� A9/2 Fire District: <br /> Q I. ❑Yes IND Does 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 /> Q2. ❑Yes e1No 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 /> 0 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 only medical gases. <br /> J C. This business operates a farm for purposes of cultivating the soil,raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes F/NO Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes o 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. 1 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 ��7 7S7L/.f=-itl,-� Date �2� I /(CAK <br /> Print Name <br /> x �/ zd��l Title aO <br /> Signature (Rev 10196) <br />