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San Joaquin County <br />DIRECTOR <br />Environmental Health Department Donna Heran, REHS <br />1868 E Hazelton Avenue PROGRAM COORDINATORS <br />Stockton, California 95205 Robert McClellon, REHS <br />Jeff Carruesco, RENS, RDI <br />Kasey Foley, REHS <br />Website: www.sjgov.org/ehd Linda Turkatte RHS <br />Phone: (209) 468-3420 r — ' a"a�t f$ <br />Fax: (209) 468-3433 :. Pdrienne Ellsaesser.REHSLJ <br />EE HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />V ° iRONMENTAL <br />A separate survey form is required for each business name and/or address in San Joachim CcurWEPA9TMENT <br />Business Name: i.iTelephone: <br />Business Site Address: 3'0 zl 50 t�7} rJ <br />Mailing Address (if different from above): I 0 %Oy" T 911M f �" CA CSO 0-4 1 Lt I � 0 <br />Business Owner(s) Name: V I --y" i� 2c Telephone: <br />Business Owner Address: — g e,; <br />Nature of Business: e ��� I )QJ Fr l films l YI L Fire District: <br />Q1. ❑ Yes Xo 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 />o Yes 0 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 questions in 01, please print, sign, and date the bottom of this form and return to the address above. <br />Q2. It Yes i 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 />q A. 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 />q B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. c Yes e�lou Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />"1VO <br />04. ❑ Yes 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 (HSC). I understand that if I own a facility or property that is used by tenants, 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 />Print Name: v t ' ' 1 \41 , 'vr- Date: —2—) � I �,4 <br />Signature: �'�� - Title: V C , V '*,W 0W�, <br />R.—dm101112 1 I & 0 00LO4OL <br />