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~' COUNTY OF SAN JOKQUIN <br /> OU!N <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 /> Phrase 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 /> Bus l ass Name: 12 vs F S_ESF <br /> Business Owner(s) Name: S1�T Telephone: <br /> Business Address: y <br /> Mailing Address (if different from above): <br /> Nature of Business: Fire Distric . 64:r4V6-_.r <br /> Q1. &Yes ONo Does your business handle a hazardous material in any quantity at an ne 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 /> Q2. ❑Yes 0Ao 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 materialsXlies <br /> business? <br /> If"Yes,"check any of the following conditions that aour 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. MYes ONo Does your business handle a acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes 36o Is your business within 1000 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 Californi 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 t&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 /> Owner or Authorized Agent: <br /> X �J-,6y '6 Date: .2yc�S <br /> Print e <br /> X Title: w NE: Q <br /> a ure <br /> F\DEVSVC\Planning Application Forms\Site Approval.(Revised 1-3-03) Page 6 of 9 <br />