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i <br /> �- Planning/Bldg. Dept. <br /> File No. <br /> osa!In. COUNTY OF SAN JOAQUIN <br /> r <br /> OFFICE OF EMERGENCY SERVICES ' RONALD E.BALDWIN <br /> a ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE �CEO/1 ��V`�� <br /> STOCKTON,CALIFORNIA 95202 <br /> TELEPHONE(209)468-3962 A n qMi <br /> . HAZARDOUS MATERIALS DIVISION(209)468-3969 JAN 19 2001 <br /> HAZARDOUS MATERIALS SURVEY FORM SANJOgOUIN COUNTY <br /> 0M OFEMSGENGYSERMES <br /> Please read the Hazardous Materials Information Guide on the back side before completing this survey form.' A separate form for <br /> each business name and/or address in San Joaquin County is required: <br /> Business Name ce-na-T' �'n C <br /> Business Owner(s) Name 2RAP-/as Phone: `' - 9(.S-,;2/ `j g <br /> Facility Address: O S, /160'y �+, q <br /> Mailing Address: 253 /2o 5S C :�-at1'ACQ fre �L, Cwt C/ l S <br /> Nature of Business: 1 -3En C&-x Fire District: mo-a,�Q 2 •.� A <br /> Ql. Yes ❑ No Does your business handle a hazardous material? Read back Daee. If you answered`No"to Question 1, <br /> 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? <br /> If you answered"No"to Question 2,go to Question 4. <br /> If you answered"Yes"to Question 2,do any of the following statements apply to your business?Read <br /> bagk l2age. <br /> ❑ A. The hazardous materials handled by this business is contained solely in a consumer product packaged for <br /> direct distribution try;and use by,the general public. <br /> ❑ B. This business operates a health care facility (i.e., doctor, dentist, veterinary...) and uses only medical <br /> 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 d"go This business or building occupant handles an Acutely Hazardous Material?Read back page. <br /> Q4. ❑ Yes ❑-No'This facility or modified facility will be within 1,000 feet of the outer boundary of a school (grades <br /> K-12). <br /> I have read the Hazardous Materials Information Guide and understand my requirements under Chapter 6.95 of the California Health <br /> and Safety Code. I understand that if the building does not currently have a tenant, that it is my responsibility to notify the <br /> occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. I declare under the penalty of <br /> perjury that this disclosure survey/exemption is true and accurate to the best of my knowledge. <br /> �Owner ror Authorized Agent/ <br /> X �v»a�CXTide 00 e <br /> Print <br /> X Date 5C C� C) <br /> Sign ure <br /> Rev:1B6 <br />