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p5v�t7�"l ale <br /> COUNTY OF SAN JOAQUIN <br /> f OFFICE OF EMERGENCY SERVICES RECEIVED <br /> �l 2101 E.Earhart Avenue, Suite 300 <br /> P r STOCKTON,CA 95202 APR 18 2014 <br /> �, TELEPHONE(209)953-6200 <br /> ENVIRONMENTAL H <br /> PERMIT/3ERVICEES� <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. q <br /> Business Name: ?"%Iw14, GoasT P-4-&V �,,e/ Telephone: ",(' 3551 <br /> Business Site Address: -741 56 $TV 414'Ow 'aVL.ob) 0 GA QS L`t a <br /> Mailing Address(if different from above): !�n�,1 <br /> Business Owner(s)Name: �. PArLWIe- �DAS`J* ��t)C62 Telephone: <br /> Business Owner Address: r�--��ppJ"+ �N/�y� <br /> Nature of Business: LAN)Ogiy ' f��JiT Fire District C� D� <br /> QI. 19yes [3No 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 [:]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 in the year? <br /> If"Yes", how long have you handled these materials at your business? 'f�� !JLON'S <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. 19Yes []No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. QYes IWNo 1s 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: <br /> OJ'(�r/�oyR!/�✓051 Date <br /> X RiKO- WA <br /> `//Y�y✓ I` Name <br /> n <br /> X Title Pl�:.t <br /> (Rev 8/08) <br />