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ot'•qut • c COUNTY OF SAN JOAQUIN �n <br /> 2` OFFICE OF EMERGENCY SERVICES <br /> Y D <br /> 2101 E. Earhart Avenue, Suite 300 <br /> Stockton, California 95206 JUL <br /> d•.. :`Q.. tk 1 Telephone(209) 953-6200 �+ 312012 <br /> t1Fpa ill 1� FAX (209)953-6268 &VY/ <br /> "�g�NI y <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY fPq�.W9 <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 /> -TWEbBusiness Name: cr <br /> n G <br /> Business Owner(s)Name: TIAMH Telephoner <br /> Business Address: �� 1 <br /> Mailing Address (if different from above): <br /> Nature of Business: Fire District: "(j <br /> Q1. JRYes ONo 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. -JQYes ONo 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 ttime�in�the <br /> ,year? <br /> If"Yes,"how long have you handled these materials at your business? ,, <br /> S <br /> If"Yes," check any of the following conditions that applies to your business. <br /> OA. 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 /> 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 /> 03. OYes *o Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes 3KNo 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: /1 <br /> X Date: <br /> X e Title:n0ilk r <br /> Si at <br /> FADevSvc\Planning Application Forms\Business License(Revised 7-14-11) Page 4 of 8 <br />