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`< PA - 0200632 <br /> COUNTY OF SAN JOAQUIN RECEIVED <br /> OFFICE OF EMERGENCY SERVICES <br /> �IoRoom 610, Courthouse JAN 1 3 2003 <br /> 222 East Weber Avenue <br /> "' Stockton, California 95202IFFICEUFEMERGENCYSE VICE: <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 and/or <br /> address in San Joaquin County Is required. <br /> Business Name: <br /> Business Owner(s)Name: <br /> it/i(Jlf.a. l' �� elephone: <br /> Business Address: l8 78 �� 99 <br /> Mailing Address(if different from above): <br /> Nature of Business: � " - Fire District: <br /> Q1. fires 0 N Does you?business handle a hazardous material in any quantity at any one time In the <br /> year? See the definition of hazardous material on the back of this form. If your answer Is <br /> No,"go to Question 4., <br /> Q2, teres O No Does your business handle a hazardous material, or a mixture containing a hazardous <br /> material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at <br /> any one time in the year? <br /> If"Yes,"hqw long have you handled these materials at your business? <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> OA. 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 /> O8. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. <br /> gt! This business operates a farm forpurposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3. A10as DNo Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. OYes 5No is your busin as within 1,000 f at of the outerboundary of a school(grades K-12)? <br /> 1 have read the Information on this form nd understan my requirements under Chapter 6.95 of the California Health and Safety Code. <br /> 1 understand that If I own a facility or pro ,erty that is ed by tenants,that It Is my responsibility to notify the tenants of the requirements <br /> which must be met prior to Issuance of a Certlilcat of Occupancy or beginning of operations. I declare under the penalty of perjury <br /> that the information provided on this disclosure rvey Is true and accurate to the best of my knowledge. <br /> Owner o�rJAuthodz/ed Agent. / �l <br /> f7 cue/ T�/lf Data: Iz —12- <br /> �jZ- <br /> P <br /> X Title: <br /> Signature <br />