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COUNTY OF SAN JOA WJIN <br /> OFFICE OF EMERGENCY SERVICES <br /> (' Z) 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 /> 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: til , aw" G6M"ER, <br /> Business Owner(s) Name: CLAI+LrL Erx1,..te.E12 Telephone: -73 . 19&0 <br /> Business Address: t l't 5 GQEE"\i1 20,pp Li VEQMURE CA 945 S <br /> PRcoPo5E17 L.00_A-rt0tiJ• <br /> Mailing Address (if different from above : �Ar t� <br /> //�1 ) 3291 W. IJ.rr. 99 S'rOC.K•rOti C4 9520x5 <br /> Nature of Business: C0 NJST-r21.t C-r10" 91614t-JAY Fire District: <br /> Q1. XYes ONo 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 back of this form. If your answer is No,"go to Question 4. <br /> Q2. XYes ONo 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? IS YEARS <br /> If "Yes,'check any of the following conditions that applies to your 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 /> DB. This business is a health care facility (doctor, dentist, veterinary, etc.) and uses only 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 /> 03. DYes 1ANo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. DYes IO(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 /> Owner or Authorized Agent: <br /> x Co� .E <br /> qw_ 17. Es," ( fz �J <br /> Date: ,.�"E 294 200-7 <br /> X _(2U <br /> /�� O.Nana, Title: PRES i DEr4-r M 5 ) <br /> f SSignatur ^-4ti <br /> F 0EVSVC•P1anning Application Fnmis�Sile Approval (Revised t-3-u3) Page 6 of 9 <br />