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Rug 01 03 03: 52p SJC COMMUNITY DEVELOPMENT 2094603163 P• 0 <br /> t 2 <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 torte. A separate survey for each business <br /> name and/or eddreg6 ; <br /> In SanJ7oaquin'Counly Is required. <br /> Na <br /> Business me: //'tr UGt i 001 6, A <br /> Business Owner(s) Name: 1 T Telephone: <br /> Business Address:_ I 0-zS I fMa("Jx tr —:N OI p e7 1=�J /I 9'7 � <br /> Mailing Address (if different from above):` -0- DOJ-I1 pQ I C)q 3jO IJ <br /> Nature of Business:_ SWIVY1M;1a9 COa( CONS')NV C'f 1(91`1 Fire District: <br /> Q1. OYes Does your business handle a hazardousmaterial 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. Oyes >4'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 200cublc 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. ❑Yes L6Vo Does your business handle an acutely hazardous material? See definition on reverse <br /> \ side of this form. <br /> f <br /> Q4. OYes mato Is your business within 1,000 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 mel 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 AuthorizeQl Agenl: <br /> X C lam— tj�g��l� Date: l/ <br /> Pte' W <br />