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ftp: ; f J <br /> 4"'" COUNTY OF SAN JUIN DEC 2 3 Z01U <br /> `�°o <br /> OFFICE OF EMERGENCY SERVICES SAN JOAQUIN COUNTY <br /> J 2101 E. Earhart Avenue, Suite 300 <br /> Stockton, California 95206 OFFICE OF EMERGENCY SERVICES <br /> ��` \ Q Telephone(209)953-6200 <br /> n /46 FAX (209)953-6268 <br /> HAZARD`US A)A S DISCLOSURE SURVEY <br /> Please read the inf rmation 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. <br /> Business Name: Q —c'RA chi <br /> Business Owner(s)Name- <br /> � nM� sz��rzS \(���\�CCt�� Telephone: <br /> Business Address: <br /> Mailing Address(if different from above): <br /> Nature of Business: \C)��r�c\rp(� Fire District: <br /> Q1. J4Yes ❑No Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br /> of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2. 15e(es ❑No Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br /> equal to or greater than 55 gallons, 500 pounds, or 200cubic 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 <br /> for direct distribution to, and use by,the general public. <br /> ❑B. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3. ❑Yes Xo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. []Yes *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 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 /> X 1 Date: 11 1 <br /> Print lam ( /� <br /> X Title: \ " \C, (\CtSI, 1:\�► <br /> Signature <br /> F:\DevSvc\Planning Application Fonns\Business License(Revised 01-28-10) Page 4 of 7 <br />