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w 4+W WrY lUUNI r uta 209 944 9015 P.02/03 <br /> l <br /> COQ OF SAN JOAQUIN <br /> OFFICE,OF EMERGENCY SERVTCES nowwu r.041,10" <br /> w ROOM 610.COURTHOUSE COMMAlcia <br /> :. 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> TV.MON£12n9)469-7962 <br /> HAZARDOUS MATERIALS DIVISION(209)46!-3%9 <br /> HAZARDOUS MATERIALS SURVEY FORM <br /> 1 <br /> Please read the info"on on the reverse aide before completing this survey form. A separate survey for each business name <br /> and/or address in San Joaquin County is r`equiled. /[ )) n t <br /> Business Name: I Lott t �I._�ej JL.h001 ill,;i. <br /> Business Owner(s)Name: Telephone: <br /> BusinessAddrous 13Ur/1 e S _ �cGtt gZI/O T <br /> Mailing Address(if dAwl ear from above): <br /> Nature of Business: f l,„a ��stri G� ft/'/-c`t6) True}mss faW <br /> foA1,4Fire District: ^r <br /> Q1. Xycs MNoiI Does your business handle a hazardous material in any quantity at any one time in the year? Sae the <br /> f definition of hazardous material on the back of this form. If your answer is"No",go to Question 4. <br /> Q2. IxYes pNo$ Does your business handle a hazatdoub material,of a mittuue 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 sty=business? _> �0 YeG/S <br /> f If "Yes",check any of the following conditions that applies to your busitim? <br /> Al 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 /> 0 BS This business is a health care facility(doctor.dentist,veterinary,etc.)and uses 9AIX medical gam- <br /> OC- <br /> uns.OC. This business operates It farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes )Q44 Does your business handle an Acutely Hazardous Martial? Sae definition on reverse side of dais form. <br /> Q4. OYes AN <br /> to your business within 1.000 feet of the outer boundary of a school(grades K-12)? <br /> ,I <br /> I have read the informkion on this form and understand my requirements under Chapter 6.95 of the""forma Health and Safety <br /> Code. I understand that if I own a facility or limperty 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 dacha under the <br /> penalty of perjury than the information provided on this disclosure survey is true and accurate to the best of ray knowledge. <br /> Owner or Authorized i genu: <br /> i <br /> x MA-RL- Cori 51--mr Dug <br /> X TWO <br /> Signature <br /> 00v logy <br /> Faurh� � �tnn,Ry <br /> 60 391id 1C1N3WN02dIAN3 1HOIdM Z919ZE860ZI 6Z:60 L66T/01/ZT <br />