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• �06-3832 <br /> RQ .y COUNTY OF SAN JOAQUIN <br /> ,o. o.coG OFFICE OF EMERGENCY SERVICES RONALD B.BALDWIN <br /> _ ? ROOM 610,COURTHOUSE <br /> " EIVED <br /> Y: K <br /> 222 EAST WEBER AVENUE <br /> .. STOCKTON,CALIFORNIA 95202 AUG , <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 SAN JOAQUIN COUNTY <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY OFFICE OF EMERGENCY SERVICES <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business name <br /> andlor address in San Joaquin County is <br /> required. <br /> /�,{p <br /> Business Name: ff r 4 R 6 u <br /> Business Owner(s)Name: K-I Rk LtJ41.G , F-74(,)G)T7C-5 WAVAG F-P-Telephone(7S-7) 8/Z 3963 <br /> Business Address: � �� �CC�i1�/ /�J �� /�) /� �1 KA ,/���7 � nr®��� <br /> Mailing Address(if different ce (y riyt,,_��_('T,�T�t 1!5&7 / """" Pei^/ &US, <br /> Nature of Business:A(i NM(_ d I�I 1"1I_/I Lit I�/ I Fire District: I"- - <br /> Ql. XYes ONo 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. XYes ONO 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 feel at any one time in the year? <br /> GOniv4u✓L`Rs �F PLvinliti�q AOHESI✓ff + t0(v&"TS - 3baL, Yi 0�Le3* cwc <br /> If"Yes",how long have you handled these materials at your business? I)e b✓) )") <br /> If "Yes",check any of the following conditions that applies to your business? <br /> ,XA. 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 /> O B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses pdy medical gases. <br /> O C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes >rNo Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. Dyes )Z�o 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 <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 I C-HA,r p,7 M40k5 /7 v�'11✓ tcr_� Date (e <br /> //�� Print Name <br /> g� r .L Y,la-t�.0 /✓7' Title <br /> Signature (Rev 10/96) <br /> V <br /> CJ Thursday,October 20,2005.max <br />