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City Bldg Dept : i <br /> Apeation# <br /> 15(jp 55 <br /> COUNTY OF SAN JOAQUIN <br /> a• <br /> OFFICE OF EMERGENCOtER}L[C8S ,ED RONALD E.BALDWIN <br /> ROOM 610,COURTHO SE v '°�D ' o <br /> 222 EAST WEBER AVENUE i Q u 2007 REb D I V E D <br /> .., STOCKTON,CALIFORNIA�34b2 <br /> ,�rPOa~ <br /> TELEPHONE(209)466-3963AN JUAUUIN UUUN I Y `+t�^ <br /> HAZARDOUS MATERIALS DIV18IME PEW BOA1CYSEFMCES JAN 2 7 2`0 <br /> HAZARDOUS MATERIALS SURVEY FORM SJVAPCD <br /> NORTHERNREGION <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business name <br /> and/or address in San Joaquin County is required. 7 <br /> Business Name: PAUFIG Lo/rST r2C1`Dt)&0V-5 <br /> Business Owner(s)Name: -a(-t Ft�- f pl—i ' ?W)10 c5C61 -Telephone: C c�10� 733/ <br /> Business Address: 741 1 STbGtC.TrtJ $T L.6aI , (-A, 9SZy0 <br /> Mailing Address(if different from above): <br /> Nature of Business: C"tjyz Y Fire District: LoD I <br /> Q 1. Wus�es []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. (Wes 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 time in the year? <br /> If"Yes",how long have you handled these materials at your business? 3 Zi !Xca rS <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 is a health care facility (doctor,dentist, veterinary,etc.)and uses pply medical gases. <br /> ❑ C. This business operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. E es ❑No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes QNo 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 M r VU, G✓N�� Date / <br /> Print Name � <br /> % Title /a .c <br /> Signature Aev 10/96) <br />