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RECEIVED <br />COUNTY OF SAN JOAQUIN OCT 13 2008 <br />Q` �? OFFICE OF EMERGENCY SERVICES SAN JOAQUIN COUNTY <br />y. I OFFICE Of EMERGENCY SERVICES <br />Room 610, Courthouse <br />222 East Weber Avenue <br />Stockton, California 95202 <br />�'FohN Telephone (209) 468-3962 <br />Hazardous Materials Division (209) 466-3969 <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />Business Name: <br />Business Owner(s) Name: <br />Business Address: <br />Mailing Address (if different from <br />Telephone: za6^ 51 Q 70b47, <br />Nature f Business: Fire District: <br />1 <br />41. Yes ONo Does your business handle a hazardous material in any quantity at any one time In the year? See the definition <br />of hazardous material on the back of this form. If your answer Is No," go to Question 4. <br />Q2. iYes ❑No Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br />equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at any one time in the year? <br />If "Yes," how long have you handled these materials at your business? <br />If " s," 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 <br />for 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 agricultural or <br />horticultural commodity. <br />Q3. ❑Yes 06 Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br />Q4. ❑Yes V 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. 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 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 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 />Print%17 <br />t� <br />F]Dev5vc61ann1ng Appllcallon FomMBuslnoss License (ReAsed 05-01-08) Page 4 of 7 <br />