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0 0 <br />(". <br />COUNTY OF SAN JOAQUIN <br />or'� <br />?� <br />OFFICE OF EMERGENCY SERVICES <br />r a <br />u: < <br />4�(�FORa <br />ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE <br />c <br />STOCKTON, CALIFORNIA 95202 <br />TELEPHONE (209) 468-3962 <br />HAZARDOUS MATERIALS DIVISION (209) 468-3969 <br />HAZARDOUS MATERIALS SURVEY FORM <br />Please read the information on the reverse side before completing this survey form. A separate <br />and/or address in S"aqum County is required. <br />Business Name: " D65 Au—p CrV) c t <br />Business Owner(s) Name: <br />Business Address: 2t <br />z ei <br />RONALD E. BALD W IN <br />COORDINATOR <br />OCT .1 3 1997 <br />Mailing Address (if differ nft frroo]m�abov • -3- lm:e <br />:e v <br />Nature of Business: u 'tom I Fire District: <br />Ql. 'Yes ONO 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. LYes ONO Does your business handle a hazardous material, or a mixture containing a hazardous material, in a <br />Vquantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic fegt at any one time in the year? <br />e NeC- Z d(U,Yn-t-, Get 55 9aA MkOf W tALn <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 ONO Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br />Q4. Yes LINO 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 />Signature <br />10-3--G-I <br />Owne r <br />(Rev 10/96) <br />Cl/ <br />