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RECEIVED <br /> COUNTY OF SAN JOAQUIN <br /> ,p OFFICE OF EMERGENCY SERVICES SEP - 2 2011 <br /> 2101 E. Earhart Avenue, Suite 300 <br /> STOCKTON,CA 95206 SAN JOAQUIN COUNTY <br /> •.<<•_ 'r ' TELEPHONE(209)953-6200 <br /> OFFICE OF EMERGENCY SERVICES <br /> I�f F -R!`y FAX:(209)953-6268 <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 and/or <br /> address in San Joaquin County is required. e <br /> Business Name: heo yzoi -t /�pC�l/l Telephone: <br /> Business Site Address: / rye./ <br /> Mailing Address(if different from above):o..Wl l0•GIl7•S,411a/0A) S) chi <br /> Business Owner(s)Name: keq p -;%A) *",)A& Telephone: <br /> Business Owner Address: �o?D�l �!. & ling2pd <br /> Nature of Business: /u GIG Fire District: <br /> Q1. [gVes []No 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 ( I0 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 /> ❑ 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 operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes Po Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes On 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: n <br /> X <br /> —Zt/ J/) i Date <br /> Print Name <br /> X /\�Z Title Ah <br /> Signature // W / (Rev 8/08) <br /> arty <br />