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�RUSIGG 3c� <br />g ttty,� San Joaquin County <br />�€ Environmental Health Department <br />1868 E Hazelton Avenue <br />.� Stockton, California 95205 <br />Website: www.$)gov.orglehd <br />Phone: (209) 468-3420 <br />Pax: (209) 466-3433 <br />ECIVD <br />',7C " 0 2016 <br />ENViR'ft -POEN 4L HEALTH <br />PERMMSERVICES <br />DIRECTOR <br />Donna Heran, REHS <br />PROGRAM COORDINATORS <br />Robert McCiellon, REHS <br />Jeff Canuesco, REHS, RDI <br />Kesey 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 x XE'1b0CA. ?S *r'oc�c�wxs • dtQgi'��f� ,Tefephane: CSO) 36c,7~ Z71., <br />Business Site Address: y0°9 `5tAAVW zk•T " 4-0t>1 :2:;2Ze c2 <br />Mailing Address (If different from above):�„3_t~_ _-'rte 5T L-jP'61 < 111-A !�25.2,4e72 <br />Business Owner(s) Name: ��. f*_,& ^; l A&IFTelephone: (, 2.09 ) - 2'725____ <br />Bus'ness Owner Address. <br />Nature of Business: C.NF.bt.Ry :PwX.,V4hlG Fire District _ l—oD1 <br />Q1 (Yes No <br />Does your business handle a hazardous material in any auanlity at any one t'me in the <br />year? See the definition of hazardous material on page 2 of this form, <br />n Yes )(Na <br />Does your business generate, treat, or store a hazardous waste in any, cua�tity? (used oil, <br />used antifreeze, waste solvent, etc.) <br />If your answer is "No" to both questions in Qt, please print, sign, and date ilia bottom of this form and return to tho address above, <br />Q2. Xyes a No <br />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 />'R.5 <br />If'Yes', how long have you handled these materials at your business? 15 t NEA, <br />If 'Yes*. check any of the following conditions that apply to your business: <br />u A. <br />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 />u B. <br />This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. 7(Yes u No <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />04 n Yes '060 <br />Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12) <br />have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br />Safety Code (NSC). I understand that if I own a facility or property that is used by lanants, 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 />Own, -!r or A.ahonzed Agent <br />Signature Mr aw R vw <br />8, -113,11 i 111.9) r. <br />