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PCUIN <br /> COUNTY OF SAN JOAQUIN <br /> y OFFICE OF EMERGENCY SERVICESOffl'c RONALD E. BALOWIN <br /> ROOM 6I0.COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> STOCKTON. CALIFORNIA 95202 E� Q <br /> ClFOR <br /> TELEPHONE(209)AGa3962 <br /> MA2AR000S MATE{OALS DIVISION(209)6663969 d <br /> Y <br /> HAZARDOUS MATERIALS SURVEY FORM <br /> Please read the Hazardous Materials Information Guide on the back side before completing this survey form. A <br /> separate form for each business name and/or address in San Joaquin County is required: <br /> Business Name: Rsoc�SS�wa <br /> Business Owner(s) Name: Phone: <br /> Facility Address: t 'AailU LC- c Ll i/L <br /> Mailing Address: —;�nx Q-Ssz-ayw C'-\k COD-13 <br /> Nature of Business: �1y bCeSS l VA Fire District: <br /> Q1. )(Yes ❑ No Does your business handle a hazardous material? Read back gage. If you answered "No" <br /> to Question 1, go to Question 4. <br /> 02. Yes ❑ No Does your business handle a hazardous material or a mixture containing a hazardous <br /> material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at <br /> any one time? <br /> If you answered "No" to Question 2, go to Question 4. <br /> If you answered "Yes" to Question 2, do any of the following statements apply to <br /> your business? Read back page. <br /> ❑ A. The hazardous materials handled by this business is contained solely in a consumer product <br /> packaged for direct distribution to, and use by, the general public. <br /> ❑ B. This business operates a health care facility (i.e., doctor, dentist, veterinary...) and uses <br /> only 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 /> 03. XYes ❑ No This business or building occupant handles an Acutely Hazardous Material? Read back cage. <br /> 04. ❑ Yes X No This facility or modified facility will be within 1,000 feet of the outer boundary of a school <br /> (grades K-12). <br /> I have read the Hazardous Materials Information Guide and understand my requirements under Chapter 6.95 of the <br /> California Health and Safety Code. I understand that if the building does not currently have a tenant, that it is my <br /> responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of <br /> Occupancy. I declare under the penalty of perjury that this disclosure survey/exemption is true and accurate to <br /> the best of my knowledge. <br /> Owner or Authorized Agent: op <br /> X Mm< � C/YmV rc, Title -C 1/1 S 4eLu i�6\ <br /> Print <br /> X Date a- �y-9� <br /> Signature <br />