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COUNTY OF SAN JOAQUIN <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Telephone (209) 468-3420 <br />FAX (209) 468-3433 <br />Website: www,sjgov.org/ehd <br />RECEIVED <br />DEC 2 9 2017 <br />ENVIRONMENTAL HEALTH <br />PERMPSERWES <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 />Business Owners) J <br />Name: Telephone: <br />(o) <br />Business c1 r4aa-,L Ove <br />Address: <br />t"fy'Q�J lJC/ vOl- � ✓7 ��r"'S'tTC !I `_C__C� <br />Mailing Address (it different from (� <br />above): <br />Nature of <br />Business: "r`...�Lk d-rnat,n�-tncr�,sc- Fire District: _ V <br />Q1.1�Yas ❑No 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 />02. iK(es []No Does your business handle a hazardous material, or a mixture containing a hazardous material In a <br />11 '" 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?�_ N ZA c4 v, <br />�� <br />a,�bfiRyti <br />If "Yes," check any of the following conditions that applies to your business. b�`�� <br />❑A. 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 />❑B. This business Is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical <br />gases. <br />❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br />agricultural or horticultural commodity. <br />Q3. ❑Yes �No Does your business handle an acutely hazardous material? See definition on reverse side of this <br />form. <br />04. ❑Yes ❑No 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_Authorizeo _ en : <br />X Date: 1� iaJ X11 <br />"t - 11 <br />X � Title: c�'4 <br />� c � a1c. 0.-ccau.r`kc <br />Signature <br />FlAppllcationsForrna&Handouts/PlanningApplfcaUons/Buslness License (Revised 02-24-16) <br />Page 4 of 6 <br />