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1 <br /> �ya`� COUNTY OF SAN AQUIN <br /> OFFICE OF EMERGENCY SERVICES RECE(!D <br /> a` < <br /> 5 2101 E. Earhart Avenue, Suite 300 <br /> Stockton, California 95206 APR 2 8 2010 <br /> Telephone(209)953-6200 <br /> cq<rFOR��P6. FAX (209)953-6268 SAN JOAQUIN COUNTY <br /> JFFICE 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: 12 A — 8WA--9 � <br /> Business Owner(s) Name: �p w r /aa nA-2 f-` Telephone: <br /> Business Address: -44&-c)s. E U 99 at) S a h{ ) CA t 1Q <br /> Mailing Address (if different from above): A l_ <br /> Nature of Business: 01041Ar .. r.An � <br /> r '1LQ4ThJ� • Fire District: lyI6AL-?i MA - <br /> Q1. ❑YesJo 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. ❑YesJflo 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"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 <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 NINO Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes Nlo 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: ,I <br /> X Date: 3) — 4 f� <br /> Prin me (1 <br /> X ^ Title: �_ J A "4 11 <br /> igratu <br /> F:\DevSvc\Planning Application Fonns\Business License(Revised 01-25-10) Page 4 of 7 <br />