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�• ,•r` `' COUNTY OF SAN JOAQUIN <br /> ` r ? OFFICE OF EMERGENCY SERVICES <br /> w, k 2101 E. Earhart Avenue, Suite 300 <br /> Stockton, California 95206 <br /> Telephone(209) 953-6200 <br /> FAX(209)953-6268 <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 <br /> and/or address in San Joaquin County is required. <br /> Business Name: LLC /� ci <br /> Business Owner(s) Name: Lf�Telephone:/�Q5�—&gg plev <br /> Business Address: 3gQ1 6, )h LSIC�5IOugh 13yJ / D4. CA `75J,3 <br /> Mailing Address(f different from above): <br /> Nature of Business: �S�oraGe Fire District: <br /> Q1. DYes 121114o 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. DYes Il;Ko 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 /> DA. 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 /> DB. This business is a health care facility(doctor,dentist,veterinary, etc.)and uses only medical gases. <br /> DC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> 03. DYes ISIllo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. DYes 96o 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 j�u��1 WPiI rY1GtY) Date: (p a _ o�C) ( L <br /> X���Print ame <br /> Title: DWne'r <br /> Signature <br /> F:\DevSvc\Planning Application Farms\Business License(Revised 01-25.10) Page 4 of 7 <br />