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Y: <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 EasfWeber Avenue <br /> Stockton, California 95202 <br /> TelephoneJ209)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: PI <br /> � ���Tdr� �f` /✓�L �J Tele �i <br /> Business Owner(s) Name: phone:)ID �y5"✓r 2- , <br /> Business Address: - y(j j'j '-D rA-r-N H HSL I ES) <br /> Mailing Address(If different from above): 14 Z'40 00 65 5 i <br /> Nature of Business: WNW- ,n,A t 41&AO-� Fire District: <br /> 01. DYes D 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 /> 02. Oyes D 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'Yes,'check any of the following conditions that applies to your business. <br /> 9A. 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 /> —9. This business is a health ce re 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 /> 03. Dyes ONo Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> 04. Dyes )21No 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 propertylhat 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: L/ <br /> X FFESQ �.E L Data: <br /> ri <br /> Signature <br />