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{ l <br /> r , .COUNTY OF SAN JCQUIN <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 /> l <br /> Business Name: ISI 0-F L— <br /> Business Owner(s) Name: t e ir OL12 a.-Telephone: <br /> Business Address: e <br /> Mailing Address(if different from above): <br /> Nature of Business: PQ C&Q h0LL2 b0q!5Fire District: L( be <br /> Q1. DYes �No Does y9d ibdsiness handle a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> 02. C]Yes o 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 200cubic feet at any one time in the year? <br /> If"Yes;" how long have•you handled these materials at your business? <br /> Y' If"Yes," check any of the following conditions that applies to your business. ; <br /> -CIA. 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 /> ak/ <br /> ObThis business is a health care facility.(doctor, dentist, veterinary, etc.)and uses qLlC medical gases. <br /> DC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or'horticultural.commodity. <br /> 0`' ©Yes'_VNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> 04- DYes (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 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 <br /> of my knowledge.,. <br /> 4 s. <br /> Owner or Authorized Agent::, F /r <br /> X PaVieliQDater f € <br /> Print Na <br /> X. 11_1,tAA01 T9_A_01,t4L.r Title: <br /> Signature , <br /> FAD VSVCTIanning Appiica6on Fams%Use Permit(Revised 05-11-09) Page 6 of 9 <br />