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w pa IM <br /> r: .a <br /> M; �< <br /> •r{t•�!�d Sid`~ <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse �� <br /> 222 East Weber Avenue <br /> Stockton, California 95202 JUL 12 2002 <br /> Telephone(209) 468-3962 <br /> Hazardous Materials Division (209)'468-3969 8i46dVA JUIN UUU.; Jy <br /> *RM(EMEkGENCYSEMgCiE, <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: I kiiLK &DC- <br /> T _ <br /> Business Owner(s) Name: l ✓ D/ Telephone: t^ �d <br /> LDCJ-. P-►fi t T i 5 -4 2 <br /> Business Address: i i�E� <br /> Mailing Address(if different from above): =/j/",-,E: <br /> Nature of Business: C� � ��� Jr T�� Fire District: I: ,,ZLOU <br /> >..H� -ten <br /> Q1. 17Yes ❑No Does your business handle a hazardous material In any quantity at anyone time in t ie <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. OYes ❑No Does your business handle a hazardous material,or a mixture containing a hazardous <br /> maieriai 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? io veQ TS <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 anly medical gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> f agricultural or horticultural commodity. <br /> Q3, InYes ❑No Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> s <br /> Q4. ❑Yes 04o Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 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 2DI I i Dater �- - U2. <br /> X p t Title: F 1 D El i I 0VJ �= Z <br /> ignature <br /> I <br />