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Jkury jusaw V 11Y <br />Environmental Health Department <br />► 1868 E Hasftan Avenue <br />Stockton, Calibmia 55205 <br />Troeplene(20M) 488-3020 <br />FM(205)4683433 <br />Webarkswwkshov.ogVeM <br />HA RUOUS MATERIALS o6CL()SURE SURVEY <br />Pleaw read the Information n pn the reverse side before wmplel irg the survey form. A separate suvey, for each business <br />name al andlor address in SJoaquin County is required. <br />downtown <br />Name: Ppb Construction Company ted. <br />a,smws Cereals) <br />Name: Nichat B. Jotes Telephone, 209 333-1116 <br />&¢Iowa <br />Address. <br />Mailing Address (f upward from <br />above): 300W Pine by Lodi Ca 95240 <br />Nature of <br />Sumnews' Heew Civil Construction Fire District Mokeunme <br />OL Was Otto Does your business MMIe a hamrdous material in any quantity at anyone time in the year? se Me <br />definitionoihas msmaterolon Mebackdtheem. Ifyooranswera No; goto Oueseon4, <br />02. Ill Use Does your business handle a Mzamous material, or a mlMure containing a hazardous material in a <br />quantity equal m or greater than 55 gallons, 500 pounds, ca Stomps feet at any one time in the year? <br />If'Yesl now long have you handled these materiae at yoka business? Admires <br />H'Yes check any W toy bloMng contliliors Mat applies b your pre'mess. <br />DA. The hazardous materials haMlW by this business is Contained solely In a consumer poNq <br />prey ages for tlhwt d¢NdNan to, and use by, the general public. <br />D& This business Is a health rare holrby (dotlor, dentist, mitheinary, els.) and uses only metlkal <br />poses. <br />OC. Thio buslnws operates a farm for purposes of cultivating the doll. raising, aharmal an <br />�[' agricultural o honkutuall Commodity <br />03, Oyes e [es your business hands an acutely hou andous material? See definition an imerse sida of this <br />form, <br />C4. Dyes ®No IsWubuslnms Mlhini,"feetof Meo0erbouMaryofasdaol(gndtl K12)? <br />I ham room Meinbrtnatim an Nlstorte and understand myrequ4 men6uWw CMpWr6g5of Me Caltlornie Health and <br />Safety Ccda, I untlers M that R I own a fwiliry or propeary the m u d byterunis, that it's my rwpansibillryto notRy the <br />tenants of the requirements which must be met poor toieswnw 0 a rffdtm NOcwpancy or beginning M operations. <br />1 declare under the penalty 0f all that the irrtmmal provided on this disclosure survey Is we and aovmbto the <br />best on my knowledge. <br />Own or Authorize tint <br />X <br />Ni e- Jon s Died <br />68 <br />QPntr m <br />x y ntle: President <br />Sigralture <br />FlMryicee s 4Wnniy iimbonwualness Llesee(Retm 0224-15) <br />Pki <br />