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COUNTY OF SAN JOUIN <br /> OFFICE OF EMERGENCY SERVICES ��" ► { <br /> _ y Room.6161Courthouse <br /> 222 —aM'Weber Avenue <br /> Stockton;'California 95262 <br /> 6h6ne.(209)"46$-3962 <br /> Hazardous, aterlals Dlyislor: (209)4'68=3969 <br /> HAZARDOUS MATERIALS,DISGLOSURE SURVEY <br /> Please read tl}e inforr anon on fhe reverse'side before completing this survey form: :A separate survey for eaci'i business <br /> name anc}/br address;irt San,Joagwn Courify is-required:' <br /> Business Narrie —.OX�!a <br /> BusinesOwner{s}Name:, Telephon� <br /> s p <br /> Business Address: M GY1 � S <br /> Mailing Address(if different from above): <br /> Nature of Business: /,�(,f] Fire District: <br /> Qi: ❑Yes 04o 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. 13Yes3EVo 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 /> 13A. 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 /> P <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 IINo D es your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes QNo Is your business within 1,000 feet of the outer bounds of a school (grades K-12 ? <br /> boundary {9 ) <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 l 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 <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> X S t Date: <br /> OS <br /> me <br /> X Title: ll - <br /> ure <br /> F OEVSVC1Planning Application FormskUse Permit.(Revised 1-2-03) Page 6 of 9 <br />