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COMPLIANCE INFO_PRE 2019
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1900 - Hazardous Materials Program
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PR0517637
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COMPLIANCE INFO_PRE 2019
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Entry Properties
Last modified
3/12/2019 11:26:06 AM
Creation date
6/9/2018 12:41:08 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1900 - Hazardous Materials Program
File Section
COMPLIANCE INFO
FileName_PostFix
PRE 2019
RECORD_ID
PR0517637
PE
1920
FACILITY_ID
FA0013533
FACILITY_NAME
PACIFIC AG RENTALS - STOCKTON
STREET_NUMBER
3540
Direction
E
STREET_NAME
CARPENTER
STREET_TYPE
RD
City
STOCKTON
Zip
95215
Supplemental fields
FilePath
\MIGRATIONS\C\CARPENTER\3540\PR0517637\COMPLIANCE INFO 2018 - PRESENT .PDF
QuestysFileName
COMPLIANCE INFO 2018 - PRESENT
QuestysRecordDate
4/10/2018 6:49:16 PM
QuestysRecordID
3850291
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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COUNTY OF SAN JOAQUIN <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Telephone (209) 468-3420 <br />FAX (209) 468-3433 <br />Website: www,sjgov.org/ehd <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 PaC I r t t1 Q q G <br />Name: <br />Business Owner(s) <br />Name: <br />Business <br />Address: <br />&+Ie J41ke Telephone: 331_%5y%- N 6 <br />r <br />SfOG��Oo <br />Mailing Address (if different from p (� // kn / I <br />above): $a0 RktC 04) #6g6 1, SQ`iA05 C'a 93 9O I <br />Nature of <br />Business: �Qu pmen+ Sa�gS F Repo r -Farm NlgcH;net y Fire District: M0(1teZulnq. RCeProtoc+.on <br />-Voi on I3-1 <br />Qt. XYes DNo Does your business handle a hazardous material in any quantity at any one time in the year? See the <br />definition of hazardous material on the back of this form. If your answer is No," go to Question 4. <br />Q2. KYes DNo Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br />quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at any one time in the year? <br />If "Yes," how long have you handled these materials at your business? I yeoir <br />If "Yes," check any of the following conditions that applies to your business. <br />DA. 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 />DB. This business is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical <br />gases. <br />DC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br />agricultural or horticultural commodity. <br />Q3. NYes DNo Does your business handle an acutely hazardous material? See definition on reverse side of this <br />form. <br />Q4. DYes ONo 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. 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. <br />I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br />best of my knowledge. <br />Owner or Authorized gent: 410/1 7 <br />X b C r E Date: <br />print NarrAjd <br />X G/ Title: Pees1 dens <br />S nature <br />F/ApplicationsFo"s&HandoutslPlanningApplications/Business License (Revised 02-24-15) <br />Page 4 of 6 <br />
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