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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 /> 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: Lre.&rVe C�I,��L�C�c'1- EnVf!'Odl h<P�tfiS, nc� <br /> Business Owner(s)Name: s Telephone: ,209-� - Lfyty <br /> Business Address: 15 -1 q 1�''LAeiT�e,Y let <br /> Mailing Address (If different from above): <br /> Nature of Business: �,4,✓I/4 S e;Lre- •S Ci-V �CF S Fire District: ' t jkyol J <br /> Q1. IdYes O 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 I%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 /> Q3. OYes CqNo Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> 04. ❑Yes (HNo Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 have reed 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. 1 <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 LU_1 -pre- L Sea- . Data: �0'3 <br /> P Int me <br /> X L' «- Title: �hZ C1 <br /> Signature <br />