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s � <br /> COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton,-California 95205 <br /> Telephone(209)468-3420 <br /> 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 form. A separate survey for each business <br /> name andior address in San Joaquin County Is required. <br /> Business <br /> Name: 16k slell b <br /> Business Owner(s) �� <br /> Name: Cwt e� Telephone: 2-0 <br /> AY 1 Vl. P_ <br /> Business // 99 <br /> Address: G 7 Cc1uT�✓(obi Z�� 3 <br /> Mailing Address(if different from L <br /> above): 36 a -W 00)"10 412, 5h UM 614 01;-2-65— <br /> Nature <br /> iLG5— <br /> Nature of <br /> Business: 665 <7U.6,411 F d C&h Vti61 P ,-r f Fire District: <br /> Gr1 a.0 ham.—S l <br /> Q1. CIYes*lo 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. OYes�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,Dr 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 /> 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 /> OB. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses 2nly medical <br /> gases. <br /> OC. This business operates a farm for purposes of cultivating the soil,raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes'dNo Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. OYes`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. 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 /> I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge. <br /> Owr�eq or Authoriz d Agent: l .— <br /> X Date: "7'/ / <br /> rint N <br /> X Title: ( (� 1 y) el, <br /> Signa re <br /> F/ApplicabonsForms&Handouts/PlanningAppligBons/Business License(Revised 02-24-15) <br /> Page 4 of 6 <br />