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COUNTY OF SAN Jr `QUIN <br /> '.. OFFICE OF EMERGENCY-6ERVICES <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 <br /> name and/or address in San Joaquin County is required <br /> Business Name The Home Church <br /> Business Owner(s) Name Tim Pollock Telephone (209) 339-7333 <br /> Business Address. 11451 North West Lane-, Lodi, CA 95242 <br /> Mailing Address (if different from above) <br /> Nature of Business. Religious Fire District. Waterloo Morada <br /> 01 OYes ®No 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 you: answer is No go to (question 4 <br /> O2 ❑Yes ®No 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 _. <br /> If "Yes. check any of the following conditions that applies to your business. <br /> 0A 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 /> ❑C This business operates a farm for purposes of cultivating the soil. raising. or harvesting an <br /> agricultural or horticultural commodity <br /> 03 ❑Yes ®No Does your business handle an acutally hazardou§material? See definition on reverse side of this form. <br /> 04 ❑Yes ®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 <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 AnL <br /> X �1t. Date: � so y <br /> N � e <br /> xTitle: <br /> gnat <br /> F\DEVS%!C7P1an vN App!,.ation Forms''Srte Apprbva! (Revrsed 6-73-oat Page 6 of 9 <br />