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Jul 0816 08:36a White Star 916 771-8478 p.1 <br /> San Joaquln County JUL U S 2016 <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> PR0h3RAM C W ROIt:::,4ORS <br /> Stockton, California 95205 1'•116,, 4; - <br /> 'Nebsile: www.sjgov.orglohJ I .,,, ..;,. rI IV <br /> Phone: (209)468-3420 "1,�,uv_'•n.,'la 1-n= <br /> Fax: (209)468-2433 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey foss Is required for each business name andlof address In San Joaquin County <br /> S'85of SR[cn/hF,vYO �/ 3714— &662 <br /> Business Name. use=.� •' Telephone: (C'ittp) <br /> Business Site Address- 2--151 I Flrr(r luny STrc&Tr Cr%- -y '2,C <br /> Mailing Address(if different from abovey <br /> Business Owner(s)Name: 2 S>Rz$rsr0* QAj§ rd Telephone: fZz— ?I/ /a/2fy <br /> Business Owner Address 1�?� f /� !/6 ,C/ ivil^ Lk 72 WAS/ <br /> Nature of Busmes-s �ff� i8402lI'J fire District: <br /> Qi. fYes No Does your business handle a hazardous material in any quamity at arty one hme In the <br /> yeah See the definition of hazardous material on page 2 of Ibis form. <br /> VYes No Does your business generate.treat,or store a hazardous waste m any-guatt-W?(used of. <br /> used antifreeze,waste solvent.etc.) <br /> If your answer Is"No"to both questions In 01,please print,sign,and dato tho bosom of this form and Mum to the address above. <br /> 02 fYes I I 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 lime m the yeaO <br /> If*Yes'.how long have you handled these materials at your business? A//(g__ <br /> t"Yes",check any of the following conditions that apply to your business: <br /> li,K 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. <br /> This business operates a farm for purposes of cultivating the soil,raising or harvesting an <br /> agricultural or horticultural commuddy. <br /> 03. n Yes ✓No Does your business handle an Acutely Hazardous Material+ See definition on page 2. <br /> 04 a Yes ✓No 13 your buslnvas vnllrin 1.000 feel of the Wer boundary of a school?(Grades a-12) <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California I-lealth and <br /> Safety Corte(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 mel prior to Issuance of a Certificate of occupancy or beginning of operations I <br /> declare under the penalty of pequry that the information provided on this disdosure survey is true and accurate to the best of <br /> my knowledge. <br /> Owner or Authorized Agent <br /> Print Name <br /> yDate: 0 <br /> /7/0 <br /> Signature. G;&AC <br /> 1- ]Y b;Ff2- <br /> 1 <br /> q,vl nMn> <br />