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.�' <br /> COUNTY OF SAN JOiJIN <br /> ;o •�oG OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse r <br /> N 222 East Weber Avenue <br /> Stockton, California 95202 <br /> `�'�;Fs•Ra�� Te1ephone.(209)468=3962 <br /> Hazardous:Materials Division (209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read`fhe information an thereverse side before completing this survey form. A separate"survey for.each business , <br /> name andloraddtess in San Joaquin b ,' '- %is`required <br /> Business Name.' <br /> Business.Owner s Name.. <br /> ( ) " Telephone: ba lora 3 <br /> i Business Address: ►��� S. Y�:1c,--1eLI�1 . i2 r� farr�-1rm C-� <br /> t�tfl <br /> Mailing Address(if different from above): 3 �� �c gam- y o I p(j <br /> Nature of Business: Fre District: <br /> Q1. ❑Yes RN 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. ❑Yes I21flo 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 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 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 dNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes ffl�o 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 Cade. I understand that if I own a facility or property that is used by tenants, that it is my responsibility to notify the <br /> t 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 <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> X 'r t:?{ c r Date: -:4 <br /> Print Mame <br /> Title:0 W )') V r-' <br /> { Signature <br /> FADEVSMPlanning Application FormslUse Permit.(Revised 1-2-03) Page 6 of 9 <br />