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\ ala � � �.2 RECEIVE <br /> / IN COUNTY OF SAN JOAQUIN OCT 12 2010 <br /> OFFICE OF EMERGENCY SERVICES <br /> (fit b e 2101 E. Earhart Avenue, Suite 300 COMMUNITY DEVELOPDAENT DEF' <br /> STOCKTOJ <br /> TELEPHONE <br /> (2 9) 53-62 r.,�y. IWED <br /> TELEPHONE(209)953-6200 ��(�����C., VV GGLLdd <br /> OCT 14 2010 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> SAN JCACUIN COUNTY <br /> Please read the information on the reverse side before completing this survey form. A separate survey f9Ff4�Y1JtE436HN(dYS <br /> address in San Joaquin County is required. <br /> Business Name: ' <br /> Telephone: <br /> Business Site Address: L-!) <br /> Mailing Address(if different from abboovv,e))::��" / <br /> Business Owner(s)Name: �,r\Yi'V IaTL� ��-�.�,)�C/l��.P.�� �(�t� Telephone: f` TL����_J <br /> Business Owner Address: ��C� � C 1��tJL9T C �"E� t � `�.� C,,-fir-., 8 -- ,�-�- <br /> Nature of Business: t Fire District: <br /> Ql. []Yes C41,lo 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 5PNo 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 ❑No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes S�No 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. 1 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: In I <br /> X —Date l�/I Ol l 1) <br /> X Title <br /> � tore <br /> (Rev 8/08) <br />