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oPQ�IM. C <br /> r.' y <br /> C `P <br /> 1�/FOPS <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: ?ZifI,0 7-0 S_,i.�G/� // / 7 <br /> Business Owner(s) Name:�"Ii✓6TO py//mac. G'�,,�. Telephone: 4 `? —4 /-198'17 <br /> Business Address: 1/0, /34K- ��c !SS amu) i//t/(,• (��4 • •Z 7���j//�/� /y <br /> Mailing Address (if different from above):_1t�0 SS �O• Aelpg iCC FVe�r'lGY/ 4[ (..df• ?� <br /> Nature of Business:7t?GLC� E j y�r`�gr (apt r1ong Fire District: <br /> Q1. ❑Yes KNo 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. []Yes ,A,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 /> ❑B. This business is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical gases. <br /> 11 C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes 51[to Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. ❑Yes 9&p Is your business within 1,500 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 X Steve Beneto Date: 11-19-03 <br /> i�lamt?� <br /> X _ Title: Aram dant <br /> / Signature <br />