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COUNTY OF SAN JUIN RECEIVED <br />OFFICE OF EMERGENCY SERVICES <br />2101 E. Earhart Avenue, Suite 300 MAY 2 7 2010 <br />fX �� Stockton, California 95206 <br />Telephone (209) 953-6200 SAN JOAQUIN COUNTY <br />FAX (209) 953-6268 OFFlCE OF EMERGENCY SERVICES <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 is required. <br />Business Name: <br />Business Owner(s) Name: <br />Business Address: <br />Mailing Address (if different from above): <br />Nature of Business: <br />Q1. ❑Yes ❑No Does your business handle a hazardous material in any <br />of hazardous material on the back of this form. If your a <br />Q2. ❑Yes ❑No Does your business handle a hazardous material, or <br />equal to or greater than 55 gallons, 500 pounds, oo <br />If "Yes," how long have you handled these <br />If "Yes," check any of the following <br />Telephone: <br />ty/at any one time in the year? See the definition <br />is No," go to Question 4. <br />e containing a hazardous material in a quantity <br />feet at any one time in the year? <br />at your business? <br />that applies to your business. <br />❑A. The hazardous materials h5iKdled by this business is contained solely in a consumer product, packaged <br />for direct distribution to, Od use by, the general public. <br />❑B. This business is a t 6alth care facility (doctor, dentist, veterinary, etc.) and uses only medical gases. <br />❑C. This businesoperates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br />Q3. ❑Yes ❑No Does your fa6siness handle an acutely hazardous material? See definition on reverse side of this form. <br />Q4. ❑Yes ❑No Is yoyfbusiness within 1,000 feet of the outer boundary of a school (grades K-12)? <br />I have read the inf mation on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br />Code. I unders nd that if I own a facility or property that is used by tenants, that it is my responsibility to notify the tenants of the <br />requirements,which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br />penalty of pelrjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br />ALRirAox isEr vP JlT/-4 THcm <br />Owner or Authorized Agent: 7— -7 <br />X d— a K POAOD4�( Date: o <br />rent Name <br />X ..vim Title: 0WA.)Z2 <br />Signature <br />FADevSvc\Planning Application Forms\Business License (Revised 01-25-10) Page 4 of 7 <br />