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COUNTY OF WAN JOAQUIN <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Telephone (209) 468-3420 <br />FAX (2091468-3433 <br />Website: www.sjgov.org/ehd <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />Please read the information on the reverse side before completing this survey form. A separate survey for each business <br />name and/or address in San Joaquin County is required. <br />Business <br />Name: <br />,F- <br />Business <br />Business Owner(s) <br />Name: <br />Business <br />Address: Z <br />Telephone: <br />Mailing Address (if different from <br />above): 02 ba(b /Ce Pee— Lir S+n� a n.,C� 9S2Q� <br />Nature of 1 � <br />Business: iN a O LIFS4 pI S7iz <br />Fire District: V}yte/tpp - rkLyt14,jj <br />01. []Yes 04o Does your business handle a hazardous material in any quantity at any one time in the year? See the <br />definition of hazardous material on the back of this form. If your answer is No," go to Question 4. <br />Q2. []Yes Ufq�o Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br />quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at 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 applies to your business. <br />OA. The hazardous materials handled by this business is contained solely in a consumer product, <br />packaged for direct distribution to, and use by, the general public. <br />OB. This business is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical <br />gases. <br />OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br />agricultural or horticultural commodity. <br />Q3. OYes RK-0—Does your business handle an acutely hazardous material? See definition on reverse side of this <br />form. <br />Q4. OYes o 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. I understand that if I own a facility or property that is used by tenants, that 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 />I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br />best of my knowledge. <br />Owner or A thorized Agent: <br />X , __ <br />r _,C ` I t�(f�A Date: 3 Ig <br />Pr i t Narne <br />X �..4-1�(.,ti— Title: �S►�%E�� <br />Signature <br />F/ApplicationsFonnsBHandouWPlanningApplications/Business License (Revised 02-24-15) <br />Page 4 of 6 <br />