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�a td COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RON LDWIN <br /> ROOM 610,COURTHOUSE C' <br /> 222 EAST WEBER AVENUE `` L ��� <br /> s �� STOCKTON,CALIFORNIA 95202 <br /> 'rtiA6'Ay'v i4 „ TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 JUL Y 0 2012 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY EN�iR ����qMq NTp <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each businessODnam-dRMENT <br /> and/or address in SanJoaquinCounty is required. <br /> Business Name: ;Ei,-- 4l F�2A{{f.--s <br /> Business Owner(s)Name: 1^Lky rA"e, Telephone: (2 oa) N06- 9209 <br /> 1 I� 1J C K <br /> Business Address: 1��I 1y�� `� I �Q.1 V T <br /> E I � CS C e`IZ' <br /> Mailing Address(if different from above): <br /> t' <br /> Nature of Business: 2OC E55 I 7.)C, Fire District: <br /> Ql. Wes ❑No Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material on the back of this form. If your answer is"No", go to Question 4. <br /> Q2- I'Yes CNo Does your business handle a hazardous material,or a mixture containing a hazardous material,in a <br /> quantity equal to or greater than 55 gallons,500 pounds,or 200 cubic feet at any one time in the year? <br /> If"Yes",how long have you handled these materials at your business? 19 11 G Li rlkS <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 for <br /> direct distribution to,and use by,the general public. <br /> Cl 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 <br /> agricultural or horticultural commodity. <br /> Q3. %Yes ❑No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. <br /> Q4. ❑Yes P51,lo 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 <br /> the 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: I <br /> X Date 61 i l l2G)'2 <br /> nt Name <br /> x Title 61 O <br /> (Rev 10/96) <br /> F <br /> Thursday, October 20, 2005.max <br />