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E:R/25/2017/TUE 07:21 AM FAX No, P,001/001 ■EN^ ■ ■ g-�r ■�■ Q F ,:� SAN JO,AQLTN COLIN'TY ENVIRONMENITTAL HEALTH DEPARTNI 1868 East Hazelton Avenue, Stockton. CA 95205-6232 RECEIVED Telephone (209) 468-3420 Fax (209) 464-0138 wrnnP.sjcehdcom AVR Z 5 2017 ENVIRONMENTAL HEALTH HAZARDOUS MATERIALS DISCLOSURE SURSERVICES A separate survey form is required for each business name and/or address in San Joaquin County. Business Name: C-HXV f�'li % 5--CdP6 9j1 Telephone: Business Site Address: 3.5 S7 Mailing Address (if different from above): Business Owner(s) Name: C/116VFOA) PFWWKI TS C69 Telephone: 9Z�AcV O Business Owner Address: 6x71 1!34�'uIN61�79 61AI 3t/ W141g:> -5c%L/ /z/}/�jUi rf 9j/53"3 Nature of Business: Fire District: �OG y/—yx— !7y Q1. Yes o No Does your business handle a hazardous material in any quantity at any one time In the year? See the definition of hazardous material on page 2 of this form. D Yes D No Does your business generate, treat, or store a hazardous waste jL9a auantjW. (used oil, used antifreeze, waste solvent, etc.) If your answer is "No" to both questions In Q1, please print, sign, and date the bottom of this form and return to the address above. Q2 Yes o No Does your business handle a hazardous materiel, or a mixture containing a hazardous l material, in a quantity equal to or greater than 55 gallons, 500 ponds, or 200 cubic feet at any one time in the year? If "Yes", how long have you handled these materials at your business? If "Yes", check any of the following conditions that apply to your business: rA. The hazardous materials handled by this business are contained solely in a consumer product packaged for direct distribution to and use by the general public. o B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an agricultural or horticultural commodity. Q3. in Yes INo Does your business handle an Acutely Hazardous Material? See definition on page 2 le Q4. in Yes Ir0 Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12) I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and 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 tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. If you answered "Yes" to Question 2, please go online to cere.caleoa.ca.gov to submit your hazardous materials information Owner or Authorized Agent: Print Name: AIC—ii A?,gW6;t Date: V—,!57 —d1 % Signature: !®/ `� Title: 1,1k-4 �Y7 EHD 18-02 1 HMBP SURVEY R.i.miW ARR Received Time Apr.25. 2017 8:14AM No.1318