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0 <br /> a4 IN San Joaquin County <br /> �O.••' u '-•.CD DIRECTOR <br /> Environmental Health Department Donna Heran,REHS <br /> y 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> Stockton, California 95205 Robert McClellon,REHS <br /> Jeff Canuesco,REHS,RDI <br /> 64 • Kasey Foley,REHS <br /> /FbRa 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: 1 1f"t_-s cJ le Telephone: <br /> Business Site Address: 1,69 MlLSEy W*s/ <br /> Mailing Address(if different from above): <br /> Business Owner(s)Name: C,ite.ts J 2 Telephone: <br /> Business Owner Address: t-6dE/L2y *Vr-- S,Aa/ t3tUAJO , CA 9YOSK <br /> Nature of Business: Fire District M0--41,1-C-CA <br /> Q1. jrYes ❑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 iw< Does your business generate,treat,or store a hazardous waste in anyguantitv7(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. q�YBs 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? CK_1Z/eW- PIC65— <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 WNo Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes li;1�0 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. <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: Aff 114A CcWTP- rZ45 Date: 0� /s� <br /> Signature: AV& Title: �� M <br /> 1 <br /> Rw, ed 1rom2 <br />