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0 <br /> 4�tN San Joaquin County <br /> >°Q Environmental Health Department DIRECTOD nnaHean,REHS <br /> N 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> Stockton, California 95205 Robert McClellon,REHS <br /> Jeff Canuesco,REHS,RDI <br /> Kasey Foley,REHS <br /> '9C}F•o RNALinda Turkatte,REHS <br /> Website: www.sJgov.org/ehd <br /> Phone: (209)468-3420 Rodney Estrada,REHS <br /> Fax: (209)468-3433 Adrienne Ellsaesser,REHS <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County. / <br /> Business Name: —?"60 l-`l� i�-te Telephone: Wq <br /> Business Site Address: I eJZ lyV �'-v^ �2 <br /> Mailing Address(if different from above): <br /> Business Owner(s)Name: d e j ),/In Telephone: W1 —q�Z,�9p— I(Q-2- <br /> Business Owner Address: :Rk Ga✓V� ryl ��/I� <br /> Nature of Business: S_P (, A 1{- Fire District: <br /> Q1. M' es ❑No 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 /> ❑Yes Ao 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�IIs"No"to both questions in Q1,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2. a(Yes o No 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? �22 <br /> If'Yes",check any of the following conditions that apply to your business: <br /> ❑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 /> ❑B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes nlo Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes of//o 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(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: K�n1� r b�TnYA Date: 7 —�L'? <br /> Signature: u Title: MA NJkC E2 <br /> 1 <br />