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COUNTY OF SAN JOAQUIN <br /> oFqutN• c <br /> >:.�'•.oG Environmental Health Department <br /> s 1868 E Hazelton Avenue <br /> " K Stockton, California 95205 <br /> Telephone (209) 468-3420 <br /> RF�F�Ra FAX (209) 468-3433 <br /> Website: www.sjgov.org/ehd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey farm. A separate survey for each business <br /> name and/or address in San Joaquin County is required. <br /> Business Name: biSPi: <br /> Business Owner(s)Name: Telephorn+e:: <br /> Business Address: 11JoLQ0k LA) et Pit^ C C <br /> - --' — M?7 <br /> Mailing Address (if different from above): <br /> Nature of Business: Fire District: d��a <br /> Q1. CYes 7�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 fort. If your answer is No,"go to Question 4, <br /> xtum <br /> rdous <br /> ial in a <br /> Q2. CYes N&o quantity <br /> anti o e equal to or greabusiness tle a hazardous er-than than 55 gallons,500'pou pounds, 200 ucontaining eet at any one time inrthe year? <br /> q tY q 9 <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 /> CA. 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 /> CB. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. <br /> CC. This business operates a farm for purposes of cultivating the sob, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. CYes �Io Does your businesshandlean acutely hazardous material? See definition on reverse side of this form. <br /> Q4. CYes 1910 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 t 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 /> OwnerorAuth'o'rized Agent: <br /> n <br /> X C -"b tt Q C'u Date: <br /> Title: <br /> Print Name <br /> Xw n <br /> Signature <br /> F:SDEVSVMPlanning Application Forrnsl.Site Approval.(Revised 02-03-10) Page 7 of 10 <br />