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SAN.JOAQUIN Environmental Health Department L-� rz ' —COUNTY— RECEIVED c,..P., Greatness grows here. ]AN 9 q 2013 HAZARDOUS MATERIALS DISCLOSURE SURVBVIIENTNI.IIEAlall UEPARr,NIE\T A separate survey form is reqy required for each business name and/or address in San Joaquin Co,int. Business Name: / �I 6 S4e �4 Z r'ii C Telephone: Business Site Address: gos�p Lz ae L1it-rs, 1,,X R6� ` f� / Mailing Address (if different from above): ��Y�/� .�� " i u.P_-��C I..JA� rJ. �_ c cte]" C61 e�YSZ } Business Owner(s) Name: I'�,. f IL tc- S -IP_ Telephone: 2 OCt ` ?P Business Owner Address: Nature of Business: A7- f C 119k 6bice, Fire District: Q1. 0 Yes YYNo 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. 0 Yes lfNo Does your business generate, treat, or store a hazardous waste in any quantity? (used oil, used antifreeze, waste solvent, etc.) If your answer is "No" to both questions in 01, please print, sign, and date the bottom of this form and return to the address above. Q2. o Yes ❑ No Does your business handle a hazardous material, are mixture containing a hazardous material, in a quantity equal to or greater than 55 gallons, 500 pounds, 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: ❑ A. 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. a B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an agricultural or horticultural commodity. Q3. 0 Yes ❑ No Does your business handle an Acutely Hazardous Material? See definition on page 2 Q4. o Yes o No 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 cers.caleoa.ca.aov to submit your hazardous materials information. Owner or Authorized Agent: y%-� Print Name. N C �s4f s, Date: Signature: Title: 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com kf-