Laserfiche WebLink
COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California95205 <br /> Telephone(209)468-3420 <br /> FAX(209)468-3433 <br /> Website:www.sjgov.orglehd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> _Please read the information on the reverse side before com_ pleting this-survey form. A separate survey for each business <br /> name and/or address in San Joaquin County is required. <br /> Business <br /> Name: Rr,u¢AT6 T2r4tlyMt �rnwiG� <br /> Business Owner(s) <br /> Name: CEFR1bTiNl� CR�N�1 Telephone:/ g <br /> Business 1. o02, <br /> d D <br /> Address: loll d 2aICE6 2 D 5 Tam 1-otU l CR !16.?05' <br /> Mailing Address(if different from <br /> above): E.D. amA (o 14-9 6T-0C1C+Mt-1 I CR • 45eq64 <br /> Nature of <br /> Business: �f�N5 55 foN Ref prig-) Fire District: <br /> Q1. ( Yes ONo 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. AYes ONo 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? <br /> If"Yes,'check any of the following conditions that applies to your business. <br /> OA. 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 /> OB. This business is a health care facility(doctor, dentist, veterinary,etc.)and uses only medical <br /> gases. <br /> i <br /> OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes ONo Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. OYes ONo Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? <br /> 1 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 A ant: <br /> X Gr��f��J�J'nNAr NA-NF1LL Date: 7^e2t -1i5' <br /> Print Na <br /> Lam'/ 4 t� C.asV <br /> X <br /> Title: if; .y H-CAcJ <br /> �' Signature <br /> F/ApplimllonsFor sBHandouts/PianningApplimUons/Business License(Revised 02-2415) <br /> Page 4 of 6 <br />