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pcylp <br /> L' <br /> v: <br /> i< <br /> ..�4. r <br /> �/FOA~ <br /> COUNTY OF SAN JOAQUIN <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 /> Please read the information on the reverse side before completing this survey form. A separate survey for each business name and/or <br /> address in San Joaquin County is required. <br /> Business Name: 3-t0C1t'j GN ArJ\PT C 1 C44Q 1-1 <br /> Business Owner(s) Name:_ `C- S-'Cj-lei 1 R tj4 V Telephone: t 0 I <br /> Business Address: 5"i ELO N�- HW 4 Q-j CIA <br /> Mailing Address(if different from above): <br /> Nature of Business: C171 �1V7-�/C('LOCI ,• Fire District: <br /> Q1. OYes to 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. OYes BJVo 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 /> If"Yes,"how long have you handled these materials at your business? <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, packaged for <br /> direct distribution to, and use by, the general oublic. <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 agricultural or <br /> horticultural commodity. <br /> Q3. OYesVo Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> 04. Yes ONo 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 Safety Code. <br /> I understand that if I own a facility or property that is used by tenants, that it is my responsibility to notify the tenants of the requirements <br /> which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury <br /> that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent. <br /> X 44 r- Date: 4065; f 2O ' ZGo 3 <br /> _ Title: PI-r'Ne.c� PFvXe N, tL <br /> S <br /> Tc 2Z ©LIVC� <br /> U APPFORMRE &1S 2( ) 6 <br />