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M <br /> r <br /> • c�ily iSA��~•< <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> Telephone! 209)468-3962 <br /> Hazardous Materials Division (209)468-3969 <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. <br /> Business Name: <br /> Business Owner(s) Name: �� a w-✓Qd �Se F� Q��Tellephone: �1 o t� 3 E l ly r <br /> ` ) <br /> Business Address: il1�.P I' ����—F� '�'� � `" <br /> Mailing Address (if different from above): <br /> Nature of Business: <br /> Fire District: <br /> Q1. Was 7u No Does your business handle a hazardous material in any quantity at any one time in the <br /> / year? See the definition of hazardous material on the back of this form. If your answer Is <br /> No;go to Question 4. <br /> o <br /> Q2. OYes I No Does your business handle a hazardous material,or a mixture containing a hazardous <br /> / material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feel at <br /> any one time in the year? <br /> If"Yes,'how long have you handled these materials at your business? <br /> If"Yos;check any of the following conditions that applies to your business. <br /> OA. 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 /> OB. This business is a health care facility(doctor, dentist,veterinary,etc.) and uses gnly medical gases. <br /> OC. Thin biminnnn opornion it fnrrn for purposes of cultivating tho soli, raising, or hnrvosting nn <br /> agricultural or horticultural commodity. <br /> Q3. Oyes /dNo Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> 04. Yes ONo Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> i <br /> 1 havereed the information on thin form and understand my requirements under Chapter e.96 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 A thorized Agent: <br /> X / Date: <br /> Print Name <br /> Title: 3— /Ij <br /> Signature <br />