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COUNTY OF SAN JCUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 2'. 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 isrequired. <br /> d 4. <br /> Business,Name: L�l f r � L/.►� �'� <br /> ._.--- <br /> Business Owner(s) Name: yd- /'� LTr,. . ",Telephone: �J3-z;' -�� <br /> �l <br /> Business Address: 113 16, 511le.rn 5�c,7 Xv 31� C4 <br /> Mailing Address(if different from above): <br /> Nature of Business: Arad ei c-t i o:7. _ Fire-District: <br /> Q1. ©Yes 06o Does your business handle a hazardous rnaterial'in any quantity at any one time in.the year? See the <br /> definition of hazardous material on the hack of this.form. If your ansvveris No,"go to Question 4. <br /> Q2. OYes dNo Does your business handle a.hazardous mated al,.or amixture 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 /> If"Yes,"check any of the following conditions'that applies to'your business.- <br /> ❑A. The hazardous materials handled by this bUsiness1s contained solely in a consumer product, <br /> K <br /> packaged for direct distribution to, and use by,1hej.general public. <br /> ❑B. This business is a healthcare facility,(doctor,,dentist, veterinary,'etc.) and uses 2UI medical gases. <br /> f 17C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> f agricultural or horticultural commodity: <br /> i <br /> Q3. ❑Yes 17ro Does your business handle an acutely hazardous material?. See definition on reverse side of this form. <br /> Q4. ❑Yes 06o 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 /> i 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 r—A a) 4-VrCA S 0 f,-N,/ Date: <br /> Print Name <br /> X ��r - Title:--Pcg.efyi-e-y- <br /> Signature <br /> F:`DEVSVCIPlanning Application Forms\Site Approval.(Revised 1-3-03) Page 6 of 9 <br />