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RECEIVED <br /> �p� AUG 2 91008 <br /> '�•-. .• ,��� <br /> OM <br /> SANJOApUIN COUNTY <br /> OMCE OF EMERGENCY SERVICES <br /> F <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> Telephone(209)468-3962 <br /> Hazardous Materials Division (209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate surrey for each business name <br /> and/or address in San Joaquin County is required. c <br /> Business Name: CDZCtCf LCcuI-Cr IeS :LLc <br /> Business Owner(s) Name: T•m Gr f S-+n(ckiu Telephone: aVf) -of31-3D9<3 <br /> Business Address: Nciol u-)atel-100 ! ��1yGk�d�, CA 4(5.Ci -, <br /> Mailing Address(if different from above): 1 <br /> Nature of Business: (�)Q.rllArtix-ALr I V) Fire District: WVQ.-LI cb -Pl arcc <br /> Q1. iYes O No Does your business handle a hazardous material in any quantity at anyone time in the year. Seethe <br /> definition of hazardous material on the back of this form. If your answer is"No,"go to Question 4. <br /> Q2. ®Yes O 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 200c any one time in the year? <br /> If"Yes," how long have you handled these materials at your business? 2�a01� <br /> If"Yes,"check any of the following conditions that apply to your business. <br /> OA. 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 /> OB. This business is a health care facility(doctor, dentist, veterinary, etc.) and uses only medical gases. <br /> OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3. OYes 0o Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes 'lANo 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:a <br /> X cbawI CL- Date: (U j3t4IO-1 <br /> .P nt e <br /> X f Title: f e.r 1 er a.( j/\,ac r 0U r <br /> $i nature <br /> Pana 4 of 5 <br />