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• <br /> OFFICE EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue, Suite 300 <br /> Stockton, California 95206 <br /> .. :-. • Telephone(209)953-6200 <br /> FAX(209)953-6263 <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 name <br /> and/or address in San Joaquin County is required. <br /> e <br /> Business Name: <br /> Business Owner(s)Name: C) I j<0 Telephone: <br /> Business Address: <br /> Mailing Address(if different from above): <br /> Nature of Business- Fire District: <br /> Q1. ®Yes VO Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br /> of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2. ❑Yes No Does your business handle a hazardous material,or a mixture containing a hazardous material in a quantity <br /> 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 /> ®A. The hazardous materials handled by this business is contained solely in a consumer product, packaged <br /> 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 agricultural or <br /> horticultural commodity.. <br /> Q3. ®Yes 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 Safety <br /> Code. I understand that if I own a facility or property that is used by tenants,that it is my responsibility to notify the tenants of the <br /> requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> 6 <br /> Owner or Authorized Agent: <br /> j��V) (A <br /> Date: <br /> PEgnatur' Na e <br /> X Title: oWAj <br /> ee <br /> F:0ev8vc\P1anning Application Fonns\Business License(Revised 7-14-11) Page 4 of 8 <br />