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� e <k3 <br /> PR COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD F.BALDWIN <br /> r ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST r :s <br /> • • ; (h• STOCKTON,CAL oxxln�o2 RECEIVED <br /> tl' V TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 JUN -E 2W <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY OFFICE OFAN JUALIU COUNCY R CES <br /> Please read the information on the reverse side before completing this survey fort. A separate survey for each business name <br /> and/or address in San Joaquin County isrequired. <br /> Business Name: ^ <br /> ('am 1" I, \no\ A <br /> Business Owner(s)Name: f!\ Telephone: 201-193-651"LBusiness Address: 31M ?"Lc C kS f)y%vL S (Kiy t CA Q Slo b <br /> Mailing Address(if different from above): <br /> ""� �" 1`. ��-t <br /> Nature of Business: Flom M1��!I (,lion W�LG�,k_ [ AyNal_is FireDistrict: 000 I 0 WL- <br /> Ql. 9' es 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. A71Yes 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 feet at any one b1d,.time in the year? n <br /> If"Yes',how long have you handled these materials at your business? Siwt ,1�� in k10 I< lqq 1 <br /> If "Yes",check any of the following conditions that applies to your business? <br /> 0 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 /> 0 B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses,pply medical gases. <br /> 0 C. This business operates a fart for purposes of cultivating the soil,raising,or harvesting an <br /> // agricultural or horticultural commodity. <br /> Q3. MCes ONO Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. OYes Ildlslo 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 We and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: ,r 1 t� <br /> X 0 h y i st n a L. Noe Date (�S <br /> X Ol „-},;- _ntN__�t, ,f� Q, Title 1�Yb��.Lk <br /> Signature tC{I t (Rev 1'0196) <br /> Thursday, October 20,2005.max <br />