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0 <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWI <br /> r.' 1 <br /> e` .< ROOM 610,COURTHOUSE DIRECTOR OF <br /> 222 EAST WEBER AVENUE EMERGENCY OPERATIONS <br /> ... > STOCKTON,CALIFORNIA 95202 DECEIVE® <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 FEB 19 2W4 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY 8piy,U1%uuIN000NIY <br /> FRM OF EMERGENCY 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 its required. <br /> Business Name: i///� z / IZ ✓ �6� 5 �r� i+�L l/7C'. <br /> Business Owner(s)Name: Tt�d l QQ r7/ Telephone: <br /> n <br /> Business Address: /`���f/ C/����� �i7l ,V:2 <br /> Mailing Address(if different from/above): <br /> Nature of Business: Fire Fire District: <br /> Ql. XYes Vo 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 IND 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 /> ❑ 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 /> ❑ C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes [;kNo Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑lyes AN 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: p <br /> X // Date <br /> Print Name ee <br /> X Title C�G5idL� <br /> Signature (Rev 4/99) <br />