Laserfiche WebLink
San Joaquin County <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />H�(;tiva) <br />Nov 0 4 20►5 <br />DIR <br />Do NT//'1 <br />PROGRAM OOPTI-1 T <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, REHS <br />Rodney Estrada, REHS <br />Adrienne Ellsaesser, REHS <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: New Cingular Wireless (AT&T) - Agent John Pek Telephone <br />Business Site Address: 3143 W. Benjamin Holt Dr Stockton, CA 95267 <br />Mailing Address (if different from above): 1665 Benvenito Lane Lincoln, CA 95648 <br />916-549-9055 <br />Business Owner(s) Name: <br />McDonalds USA Telephone: 209-952-2444 <br />Business Owner Address: <br />3143 W. Benjamin Holt Dr Stockton, CA 95267 <br />Nature of Business: Unmanned <br />Wireless Facility Fire District: <br />Q1. ❑ Yes X No <br />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 page 2 of this form. <br />Fi Yes X No <br />Does your business generate, treat, or store a hazardous waste in any quantity? (used oil, <br />used antifreeze, waste solvent, etc.) <br />If your answer is "No" to both <br />questions in Q1, please print, sign, and date the bottom of this form and return to the address above. <br />02. ❑ Yes ❑ No <br />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 200 cubic 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 apply to your business: <br />n A. <br />The hazardous materials handled by this business are contained solely in a consumer <br />product packaged for direct distribution to and use by the general public. <br />B. <br />This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />03. ❑ Yes ii No <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. i i Yes i i No <br />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 ,a d <br />Safety Code (HSC). I understand that if I own a facility or property that is used by tenants, respotsi ) i tb 1. riot er <br />tenants of the requirements which must be met prior to issuance of a Certificate of Occupa begi rnrFg :oi oraiibn8 .L -- <br />declare under the penalty of perjury that the information provided on this disclosure survey i tr ncf arms to the best of <br />my knowledge. <br />(jCT L 7 t � <br />Owner or Authorized Agent: CITY OF STOCKTON <br />Print Name: �oho tk Date: 10.26-15PERMIT CENTER I PLANNING DIV. <br />Signature: Title: %1 ��F'-r 1 r <br />Revisetl 11/07/12 <br />on y <br />e <br />