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x0 - <br /> � v• �x <br /> OM <br /> f <br /> 1 <br /> COUNTY OF SAN JOAQUIN <br /> 'a <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> f Stockton, California 95202 <br /> Telephone (209)468-3962 <br /> Hazardous Materials Division (209)468-3969 <br /> f HAZARDOUS MATERIALS DiSCLOSURE SURVEY <br /> I Please read the information on the reverse side before completing this survey A separate survey for each business <br /> form <br /> name and/or address in San Joaquin County is required. <br /> Business Name: <br /> -P K-4 <br /> SES <br /> Business Owner(s) Name: S-WI N D <br /> Le a.) Telephone: S3 <br /> Business Address: _ N <br /> g7b t.. <br /> Mailing Address (if-different from above): Sao <br /> Cflmp_ g533r <br /> Nature of Business: <br /> Q1 ❑Yes No y Fire District: <br /> Does our business handle a hazardous material in an <br /> y quantity at ame in the <br /> Year? See the definition of hazardous material on the back of this form f yoneour answer is <br /> No,"go to Question 4. <br /> Q2• ❑Yes No Does your business handle a hazardous material, or a mixture containing <br /> material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200c tic feet at <br /> any one time in the year? <br /> If"Yes,"how long have you handled these materials at your business? <br /> I <br /> 4 <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> I' <br /> OA. The hazardous materials handled by this business is contained solely in a consumer product, z <br /> packaged for direct distribution to, and use by, the general public. <br /> ,j <br /> ©B. This business is a healthcare facility(doctor, dentist, veterinary, etc.)and uses 2nly 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 acutell hazardous material? See definition on reverse <br /> ` side of this form. <br /> Q4' ❑Yes /ANo 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 <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, i <br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of <br /> my knowledge. <br /> Owner or Authorized Agent: i <br /> X Date: ro _ b 0 <br /> Pri # ame <br /> X e Title: <br /> Signature <br /> 1 <br /> ii <br /> E <br /> i <br /> h <br />