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Oct-211-99 02 : 20P SJC Com ,;ty Dev - Dapt - 209 4( 3163 P -02 <br /> w.r.. COUNTY OF SAN JOAQUIN <br /> OFFICE OF]EMERGENCY SERVICES <br /> kONAt.D H.BAL7)Nnry <br /> ROOM 610,COURTHOUSE CboRDINA'rnR <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> 'rE1.F-P1I0NE(2n9)468-3962 <br /> HAZARIMNS MATLAIALS DIVISION(209)468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the infnmtntinn on the reverse side before completing this survey form. A separate survey for each business name <br /> and/or address in San JoaquinCountyis required. I <br /> HusinessNamc: TQ1c1T1���" SOMI , C�elC.I12r� Aggt qQ+� <br /> Business Owner(s)Name: Tr 1"I¢, pYbp2r 112.5 NG. quo /404 -339 <br /> Business Address: PO:_ 1-3X ! WZ .-.l'LC-'t�Q.1"r1 n CA 95 351 - i002-.- - <br /> Mailing Address(if different from above): NI <br /> Nature of Business: S � C-vel mtntnj �Kose �'roge.r�Y ) Fire District: Tr�yRtuLa. R;i-e. 1.J151rtCl <br /> �� — -- L <br /> Q 1. X 'Yes !--No Dues your husiness handle a hazardous material in any quantity at any one time in the year? Sec the <br /> definition of hazardous material on the back of this form. II'your answer in "No", go to Question 4. <br /> Q2. �Ycs '-'No 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,5W pounds, or 200 cubic feet at any one time in the year? <br /> 11 "Yes',how lona have you handled these materials at your business? _ L�9�0 <br /> If "Yes",check any of the following conditions Ulat applies to your business? <br /> L. A. The hazardous materials handled by this business is contained solely in a consumer product packaged for <br /> direct distribution to, and use by, the gencral public. <br /> . 13. This business is a health earn facility(doctor,dentist,veterinary,etc.)and uses only medical gases. <br /> `-i C. This business operates a farm for purposes of cultivating the soil,raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. Yes gNo Does your business handle an Acutely Hazardous Material? Sec definition on reverse side of this form. <br /> Q4. L.!Yes /// 'N o 6-your business within 1,000 feet of the outer boundary of a school(grades K-12)? <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br /> Code, I understand that if I own a facility or property (tint is used by tenants, that it is my responsibility to notify the tenants of <br /> the requirements which must be met prior to issuance of a Certilivatc of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knnwledge. <br /> Owner or Authorized Agent: <br /> x Lillie- Qe e L Date C)r_t 25� 1999 <br /> Pitt Name <br /> X _� 7 Title �F'tb 2c� MQiI'l0. e� <br /> 1 v Signature fRev 0/96) <br />