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0 <br /> San Joaquin County <br /> u�.......... ° <br /> Environmental Health Department DDoEnaHeran,REHS <br /> 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> C <br /> ` Stockton, California 95205 Robert MoClellon,REHS <br /> Jeff Carruesco,REHS,RDI <br /> ;p Kasey Foley,REHS <br /> H� SORa Website: www.sjgov.org/ehd Linda Turkatte,REHS <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: EA'\cO c- � r L7 j?>IP .Telephone: 209—633-60 3b <br /> . <br /> Business Site Address: 2q-70 � • Cs ra.V,k LaV\42_ ZJ 'i—r%ci_��V 3 014 <br /> Mailing Address(if different from above): <br /> Business Owner(s)Name: Cy)r oy e— P C-1(YC l-L C- Telephone: 7 ly' Zit--la O O <br /> Business Owner Address: _6c>6iS US') FJ`( `1Lallz-S �1C �S 7Ltq <br /> Nature of Business: ASS I J nck o y\l• - Fire District: TjfU'sm IP�:Pk-2- <br /> Q1. 31rYes ❑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 ❑No 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 is"No"to both questions in Q1,please prink sign,and date the bottom of this form and return to the address above. <br /> Q2. Yes ❑ No Does your business handle a hazardous material, or a mixture containing a hazardous <br /> material, in a quanfity 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"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. o Yes OINo Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes § No 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(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: 1 <br /> Print Name: 5�1t\fti✓\ Date: 2� l <br /> Signature: Title: �elAe�ral fCx1/�� N <br /> 1 <br /> Revved ttm'rnz <br />