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T,]JIN <br /> r I� it COUNTY OF SAN JOAQUIN <br /> T I <br /> OFFICE CF EMERGENCY SERVICES.90^JN ,tIO. C]U,rT, nON�L] �_ BALpWIN <br /> aus[ <br /> E3ER AVENUEcoon aln.ron <br /> 2�2 �5' W <br /> A �r SICCf<TCN, CALIFORNIA 95202 <br /> T[LF.h W(}09) ntiB 39ez <br /> N.Unao" M.rv,uV Olm31cN(20911 8.3909 <br /> HAZARDOUS MATERIALS SURVEY FORM <br /> Please read the Hazardous Materials Information Guide an the back side before completing this survey form. A <br /> separate form for each business name and/or address In San Joaquin County is required: <br /> Business Name: __Trinity Baptist DBA: Southwiuds Church <br /> Business Owner(s) Name: Southwluds Church <br /> Phone: 835-4673 <br /> Facility Address: Parcel /212-04-02 <br /> Mailing Address: post Office Box 238 <br /> Nature of Business: Church <br /> Fire District: Tracy Rural <br /> Q1. Q Yes tib No Does your business handle a hazardous material? Feed b_ ack o� <br /> to Question 1, go to Question 4. If you answered -W <br /> C2. O Yes %,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 200 cubic feet at <br /> any one time? <br /> If you answered 'No' to Question 2, go to Question 4. <br /> If you answered "Yes' to Question 2, do any of the following statements apply to <br /> your business? Read back oaee. <br /> U A. 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 /> Q S. This business operates a health care facility (i.e., doctor, dentist, veterinary...) and uses <br /> my mecicai gases. <br /> O C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> .O Yes AI No This business or building occupant handles an Acutely Hazarcous Material? Readback cage. <br /> C4" O Yes J� No This facility or modified facility will be within 1,000 feet of the outer boundary of a school <br /> (grades K-12). <br /> I have read the Hazardous Materials Inforrnaticn Guide and understand my requirements under Chacter 6.45 of the <br /> it is my <br /> responsibility to notify the occupant of the requirements which must be met prior to Issuance of a Certificate of <br /> California Health and Safetv Code. I understand that if the building does not currently have a tenant, that <br /> Occupancy. I declare under the penalty of perjury that this disclosure survey/exempt <br /> ion is true and accurate to <br /> the best of my knowledge. <br /> Cwner or Authorized Agent: <br /> Int Tice <br /> X <br /> S�9 tore Date <br /> J / ' <br />