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COUNTY OF SAN JOAQUIN <br /> a"i" OFFICE OF EMERGENCY SERVICES <br /> a Room 610, Courthouse <br /> yr t15n :[ nn� <br /> ccc East VVe u;r r <br /> ie-ac <br /> Stockton, California 95202 <br /> ��LiFp-�2N`P 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: - <br /> Business Owner(s) Name: rA z 7 r.j: �. i'l�Pt�-- _ Telephone: <br /> Business Address: ►),nl _SZ:) vrv4 ;r a.c__.oco <br /> Mailing Address(if different from above): <br /> Nature of Business; Fire District: <br /> Q1. ®'Ies 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 /> 02. ®Yes EINo 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? yrs. <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 /> ©B. This business is a health care facility(doctor,dentist,veterinary,etc-)and uses only medical gases. <br /> tin an <br /> of cultivating the soil raising, or harvesting DC. This business operates a farm for purposes g g <br /> agricultural or horticultural commodity. <br /> Q3. ©Yes iI(No DoesY our business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes I�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. 1 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: J r <br /> X �,l1 ! Date: <br /> n N <br /> X - Title: C <br /> Signal re <br /> rr-,nF:k/C1/rXPrnnninn A.Hi[.Mn FOnnslSite Awavat-(Revised 1-3-03) Page 6 of 9 <br />