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I <br /> qa�y COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALDE.BALDWIN <br /> ;.•�•,oma <br /> '_•+ ROOM610,COURTHOUSE D <br /> C <br /> 222 EAST WEBER AVENUE RECMC <br /> �.. STOCKTON,CALIFORNIA 95202 AUG 2 9 ppO� <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 SM J0AQ1JlN uuUNTy <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY 0MOFEMERGENCYSFNI6E8 <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 /> BusinessName: 4x& S5 <br /> Business Owner(s)Name: /(d^C)Nf` ` Telephone: 1160 -(OF-77 <br /> Business Address: ����C1HW�v q` jRY�C�L�t t1k • T52f1� <br /> Mailing Address(if different from above): Y . leu 3� _ 2^S1�Cw 1L'^ `► �zCaS <br /> Nature of Business: C)/Pal e Ie 4 cu r A�� Fire District:Y v oVkTA c t VYMr <br /> QL ❑Yes 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 ❑No 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 /> E 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 ',:]No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes V-X�Ols 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 1 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: <br /> X Date <br /> r <br /> int Na <br /> X_ _ Title •� qs��• <br /> (Rev 10/901 <br />