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COUNTY OF SAN JOAQuIN <br /> �oP°U'"'•co 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 <br /> name and/or address in San Joaquin County is required. <br /> Business Name: <br /> Business Owner(s)Name: -A-r t Telephone:(-�qtb�iwy � <br /> Business Address: <br /> Mailing Address(if different from above): /1G0r�c z ems-/ <br /> "�k. s CA- 4. 7(0'! <br /> Nature of Business: �' n,c til >�S VIT-y _ Fire District: <br /> Q1.AYes ❑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 your answer is No,"go to Question 4. <br /> Q2. -gYes ❑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�yallon 500 pounds,or 200cubic feet at any one time in the year? <br /> Zoo CJS= '� �itte�� c 1 w £�n3L '•-rte. <br /> If"Yes,"how long have you handled these materials at your business?St�C� Z60-z' <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> ❑A. 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 /> Q3. ❑Yes '5�No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. ❑Yes'*o 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 1 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 orized Ag nt: �f <br /> X Gv i �J Date: <br /> X Title: Ir�� <br /> Signature <br /> Pana R of Q <br />