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uocuNgn tnveiope iu: r44uutt3u-uut5U-4Z010-t5ZnU-biturtAUH0t0 <br />San Joaquin County <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />RECEIVEL) <br />JUL 130 <br />ENV'RONMEN;AL HEALTH <br />PERMIT/SERV,^F,,� <br />DIRECTOR <br />Donna Heran, REHS <br />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, REHS <br />Rodney Estrada. REHS <br />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: Arco ampm Telephone: (209) 339-2371 <br />Business Site Address: 255 E Harney Lane, Lodi, CA, 95240 <br />Mailing Address (if different from above) <br />Business Owner(s) Name: Dharni Lada. LLC <br />Business Owner Address: Not provided to applicant <br />Nature of Business: Convenience Store/Gas Station <br />Telephone:(209) 339-2371 <br />Fire District Lodi Fire Department <br />Q1 ,f Yes 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 />,l 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 print, sign, and date the bottom of this form and return to the address above. <br />Q2 Yes i(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? <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. i Yes ir No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4 w(Yes o 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: <br />Print Name Dharni Lada, LLC <br />Date <br />EDocui9nedbY:17/14/2018 <br />.,f OU.AyLt t Title: <br />1 <br />