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COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> Telephone(209)468-3420 <br /> FAX(209)468-3433 <br /> Website:www.sjgov.org/ehd <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 <br /> name and/or address in San Joaquin County is required. w "' <br /> Business <br /> Name: d J 40r, hAy 1\� <br /> Business Owner(s) Telephone: �l( <br /> Name: `C (+] E . p�CVY eye S� 2 <br /> Business I, y�, �1 <br /> Address: � � k'�C,r1 �T 1 'I1 j L�l <br /> Mailing Address(if different from <br /> above): <br /> Nature of <br /> Business Fire District: <br /> Q1. ❑Yes Flo Does your business handle a hazardous material in any quantity at any one time in the year?-See the <br /> Zo <br /> efinition of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2_ ❑Yes oesY our business handle a hazardous material,or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons, 5.00 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 /> ❑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 is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical <br /> 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 0 <br /> Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> n. <br /> Q4. ❑Yes00/11:6" r youbusiness within 1,000 feet of the outer boundary of a school(grades K-12)? <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code. I understand that if I own a facility or property that is used by tenants, that it is my responsibility to notify the <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. <br /> I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge. <br /> Owner or Authorized A ent: <br /> X_ Date: t"2— 01 <br /> P int Narae <br /> G <br /> X Title: <br /> ig re <br /> FlApplicationsForms&Handouts/PlanningApplications/Business License(Revised 02-24-15) <br /> Page 4 of 6 <br />