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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: AT f f t.-II lt-E C ,,- S ir <br /> Business Owner(s) Name: A7- T- )At/jLE 4-E-5S Telephone: S)33U - S 75/1 <br /> Business Address: .2 71Z 49 Pe"o S oEta- P.t ruc 0 Mt <br /> Mailing Address(if different from above): SA An <br /> Nature of Business: [A/'2G CZSS %2f4A e4 APq LWM47Warire District: <br /> Q1. OYes ANo 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 /> Q2. OYes 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 feet at <br /> 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 /> 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 only medical gases. <br /> OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. DYes C.tiNo Does your business handle an acutely hazardous material? See definition on reverse <br /> /I side of this form. <br /> Q4. OYes A�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 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: <br /> X 44eu4,0 `i}loMAJ" Date:—YL-3 'U`( <br /> Print Nva <br /> X iC �L- Title: Q HINT <br /> —`�D Signature <br />