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San Joaquin County <br /> op45!!,N DIRECTOR <br /> Environmental <br /> Environmental Health Department Donna Heran,REHS <br /> 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> Stockton, California 95205 Robertlon,REHS <br /> Jeff Canrruescuesco,REHS,RDI <br /> Kasey Foley,REHS <br /> o'R° Linda Turkatte,REHS <br /> Website: www.sjgov.arg/ehd <br /> Phone: (209)468-3420 Rodney Estrada,REHS <br /> Fax: (209)468-3433 Adrienne Ellsaesser,REHS <br /> HAZARDOUS MATERIALS D9SCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County. <br /> nn +7A <br /> Business Name: kljb� 05 FVZ�O N�tCALJ �LTelephone: -9-Oct— 835 — 7�5 <br /> Business Site Address:g`l 3 1 N A/XLE E 12t) -7 A 32ACY1 Chi 65 30 9 <br /> Mailing Address(if different from above): <br /> Business Owner(s)Name: Que)iOS P6S-rAVeA/Jf— WG Telephone: <br /> Business Owner Address: (9Do�- W ek br H-r tnAc e —Ir 300 C A e L.5 6�, CA 952 nc <br /> Nature of Business: f STIa ur2N tJT Fire District <br /> Q1. as-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 /> ❑Yes dtNo 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. yt_Yes ❑ 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? pt.T a p03 <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 i&No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes QNo 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: aZ4J Date: <br /> Signature: Title: J<Z�o 1b S( 1 MAL)A(K6P--- <br /> 1 <br />