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Business Nan <br />Business Site <br />San Joaquin County <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sjgov.orglehd <br />Phone: (209) 468-3420 <br />Fax: 1209) 468.3433 <br />RECEIVED <br />SEP 13 2017 <br />DIRECTOR�r���/�p <br />Donna Hetynt.R WrONMENTAL HEALTH <br />PROGRAM COORDIMIIYO2ARTMENT <br />Robert McClelbn, RENS <br />Jeff Canuesco. RENS. RDI <br />Kaley Foley. REHS <br />Unda Turkahe. REHS <br />Rodney Estrada. REHS <br />Adrienne Ellsaesser, REHS <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate sunray form Is required for each business rame and/or address in San Joaquin County, <br />Mailing Address (ifdifferent from above): <br />YC-'�C1�1' <br />t1�� k UCTelephone: <br />y rQ s'- Q%1`lA2 <br />Business Owners) Name: A- � fC�_ Telephone: 1 - `-� } <br />^yBusinessOwner Address ill 1N,- CtX �i pnl �cyora� C.4 Q CJF <br />Nature of Business: \'iU-Q,� K-Y1��vC .Sr9_ �C� S Fire Distract: <br />Q1. ){lyes c No Does your business handle a hazardous material to any cuantity at any one time in the <br />year? See the definition of hazardous material on page 2 of this form. <br />KYes ONO Does your business generate, treat, or store a hazardous waste in anv guaranty? (used oil, <br />used antifreeze, waste solvent, etc.) <br />II your answerls'No' to both questions In 01, please print, sign, and date the bottom of this form and return to the address above. <br />02. �es a No Does your business handle a hazardous material, or a mixture Antaining 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 -Yee, check any of the following conditions that apply to your business: <br />crA, 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 />o B. This business operates a fans for purposes of cultivating the soil, raising or harvesting an <br />agriculturat or horicultural commodity. <br />03. D Yes Ko Does your business handle an Acutely Hazardous Material? See definition on page 2 <br />04. o Yes PNo Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12) <br />I have read the infoenabon 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 Auth-med Agent: <br />Print Name: __'ll \HCl d�G� r lcA a, Cate: <br />\v A� <br />Signature. TAIe'. <br />�l ,k w�r,4 /=l �luy a <br />l,'d OL94991760Z said pest sofiegiy <br />