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_ COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue, Suite 3— <br /> Stockton, California 95202 <br /> Telephone (209)953-6200 <br /> Fax 209 953-6268 <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 /> r <br /> Business Name: � ', - ��.. 1,�; C�. <br /> Business Owner(s)Name: Telephone: <br /> Business Address: <br /> Mailing Address(if different from above): <br /> Nature of Business: j '1? Fire District: r €.��r :.i�..i Y',. "?. ...._ <br /> F. <br /> Q1. ®des ©No Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material on the track of this form. ff your answer is No,'go to Question 4, <br /> Q2. OYes I;TKo Does your business handle a hazardous material.or a mixture Containing a hazardous material In a <br /> quantity equal to or greater than 55 gallons, 500 pounds,or 20Dcubic feet at any one time in the year? <br /> If'Yes,'how long have you handled these materials at your business? <br /> If"Yes,"cheek any of the following conditions that applies to your business. <br /> ❑A. The hazardous materials handled by this business is contained solely in a consumer product, <br /> packaged for direct distribution lo,and use by, the general public. <br /> CIB. This business is a health care facility(doctor.dentist,veterinary,etc.)and uses ally medical gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an <br /> agricuttural or horticultural commodity. <br /> Q3. DYes 19fifo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> 04. OYes ©No 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 Califomia Health and <br /> Safety Code. I understand that if 1 own a facility or property that is used by tenants,that it is my responsibility to notHy the <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. <br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> X ' 1e;(S' Hate: ! !/ <br /> X Title: fAL7` ?Iw•r12E2 �Jj <br /> F 0EVSVC1Plenning Application F"ms%Use Pemtl.(Re"sed 02-0310) Page 6 of 9 <br />