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r <br /> U IN <br /> 2: c COUNTY OF SAN JOAQUIN <br /> < OFFICE OF EMERGENCY SERVICES RONALD E. BALDWIN <br /> < <br /> .Rr _�'• ROOM 610,COURTNOIISE COOROINA;OR <br /> 222 EAST WEBER AVENUE <br /> 9CiFOPN <br /> lP STOCKTON, CALIFORNIA 95202 <br /> TELEPHONE(2091 4683962 <br /> HAZARDOUS MATERIALS DIVISION (209) 4663969 <br /> Exemption verified and approved by, <br /> EXEMPTION STATEMENT nspecOto° ', DdeTPfJ�G <br /> Approved Reject <br /> I understand the requirements of Chapter 6.95, Division 20, Section 25500 et seq. of the Califomia <br /> Health and Safety Code which pertains to emergency planning by businesses using hazardous materials. <br /> My business claims the following exemption(s) from the Hazardous Material Management Plan require- <br /> ments: <br /> i It does not handle a hazardous material,or a mixture containing a hazardous material,in a quantity equal to or greater <br /> than 55 gallons,500 pounds,or 200 cubic feet at standard temperature and pressure for compressed gas at anyone time <br /> or an acutely hazardous material in quantities greater than the associated threshold planning quantity. <br /> 0 The hazardous material handled by this business is contained solely in a consumer product packaged for direct dis- <br /> tribution to,and use by, the general public(i.e.retail). <br /> This business operates a farm for purposes of cultivating the soil or raising or harvesting an agricultural or horti- <br /> cultural commodity. (Checking this box will put your business in the Farm Inventory Program). <br /> 0 This business operates a health care facility and uses only medical gases(i.e.doctor,dentist,veterinary...). <br /> Q Other (Describe in detail for review by administering agency). <br /> NameofBusiness Vk E .3., IU <br /> f <br /> Nature of Business IV-e r <br /> ,, ��Jf)),,1A (� <br /> Mailing Address V�/ lr�� < VVI y VPhone( <br /> City �G� �r II Zip Code <br /> Facility Addresss 15q� Phone( ) <br /> City Zip Code <br /> r � f <br /> Nearest intersection of facility site � !� ! Fire District 13�41/7 <br /> I declare under penalty of perjury that this statement is true and accurate to the best of my knowledge and is made in the <br /> City of aliform/a. <br /> Owner/Manager � r Title <br /> Print Name <br /> Signature Date <br /> Signatum in Ink 6192 <br />