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r <br /> r ` <br /> t1VIN <br /> =1Q�r 02 <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> ROOM 610,COURTHOUSE DIRECTOR OF <br /> 222 EAST WEBER AVENUE EMERGENCY OPERATIONS <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 form_ A separate survey for each business <br /> name andlor address in San Joaquin.County is required. <br /> Business Hames. METF O?GS-.TCA LAX— <br /> , <br /> Biusiness.Owner(s) <br /> X— <br /> Business.Owner(s)Name ..... „Telephone: <br /> Business Address:Iu' oger !e" 09*J/ er t sr> <br /> Mailing Address.(if different from above):._---_._..,_--- <br /> Nature of Business T61 �GpN1UI�lCA" IONS Fire District__- <br /> Qt. ❑Yes Ig No Dees 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. Dyes SAO Does your business handle a hazardous material,or a mixture containing'a hazardous <br /> Ei material in a quantity equal to or greater than 55 gallons,500 pounds,or200cubic feet at <br /> any one time in the year? <br /> I <br /> If"Yes:'how"have you handled these materials al your business?_._,__ <br /> I <br /> If'Yes,'check any of the following conditions that applies to your business. <br /> I <br /> itefialardousYsratmiMsfaaid' by this- Tonlained"Fely+n consume(prod .— <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 /> 03. Dyes .Clo Does your business handle an Acutely Hazardous Material? See definition on reverse <br /> side of this form. <br /> 04. Dyes [916o is your business within 1,000 feet of the outer boundary of a school(grades 1-12)? <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 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 agcprate to the best of <br /> my knowledge. <br /> Owner or Authorized Agent: <br /> x �t°m f rl* W « bate: r-' b'Pri 5 <br /> x Title: <br /> Si fur <br /> avuK�ae.aer xrv.woaa� I <br />