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• 1.,Q W A <br /> 2: Z <br /> N: < <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> // �a 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: 4�-?o ( so l Zi-i J L,/—C <br /> Business Ownor(s) Name: 1,4z"IY' 7 �-/,3:re,lophone: o c 7 7b2 <br /> Business Address: _�'Oda.sc� 7Y <br /> Tv C-C"leer / <br /> Mailing Address (if different from above): �0 0O -=�%c/ hum <br /> Nature of Business:/ �QCr'N -- l�/hP �L(�� a ' ,Ci-fire District: <br /> Q1. ❑Yes �No Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on the back of this form. If your answer is <br /> No,"go to Question 4. <br /> Q2. ❑Yes �240 Does your business handle a hazardous material, or a mixture containing a hazardous <br /> material in a quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at <br /> 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, <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 Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. ❑Yes 0q10" 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 8.95 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. I <br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of <br /> my knowledge. <br /> Owner or Authorized Agent: <br /> X Date: Q �O7 <br /> Print e <br /> X <br /> Title: r /tel�..�� •r <br /> Signature T <br />