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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 85202 <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)469--1969 <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: J ffi T oNew �7 <br /> Business Owner(s)Name: <br /> �y ��J W r � Telephone: (� C1 b I��_"T K <br /> Business Address: tDll`rJ 0 j �1/[}r� i _n_{' bt�s�,n��a�N�w �yt1� <br /> 5799 <br /> Mailing Address(d different from above):�•O [nJl� D 1! M 3�/ `��t"" +`On t� v f ` <br /> Nature of Business: � Fire DisVict: <br /> i / <br /> fl1. I�Yes ❑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 /> Q2. Vas ONo 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 /> ak y+ co dyuc4e <br /> Ff'Yes;how bug have you handled these materials at your business? S�� <br /> if-Yes,*check any of the following conditions that applies to your business- <br /> .13A- The hazardous materials handled by this business is contained solely in a consumar.product, <br /> -- pa a for-diFMIdsTnitls V,-tho generatpublic. <br /> ❑B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses 9ft 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 flNo Does your business handle an Acutely Hazardous Material? See definition on reverse <br /> _� side of this form. <br /> 04. C3Yes VlN 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 met 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 /> E <br /> Owner or Au Age �� { <br /> x A � t�.41 L✓` Dater <br /> x ri 1� <br /> Title: M�&K �T� <br /> i Signature <br /> e <br /> f <br /> I <br /> i <br /> n,ruc�voraaray.ateblm 1 <br />