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vUUN I I ur ·~M.N UUM.\olUII'4 <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 />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />Please read the information on the reverse side before completing this survey form . <br />name and/or address in San Joaquin Coun ty is required. <br />A separate survey for each business <br />Business <br />Name : Ford Construction Company Inc . <br />Bus iness Owner(s) <br />Name : Nicholas B. Jones Telephone: 209 333-1116 <br />Business <br />Address : 12505 Brandt Rd . Lockeford Ca 95237 <br />Mailing Address (if different from <br />above): 300 W. Pine St. Lodi Ca 95240 <br />Nature of <br />Business : Heavy Civil Construction Fire District: Mokelumne <br />Q1. OOYes DNo 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 . !EYes DNo 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 />lf"Yes," how long have you handlectthese materials at your business? 40 Years <br />If "Yes , • check-any of the following conditions that applies to your business . <br />DA. 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 />DB . This business is a health care facility (doctor, dentist , veterinary, etc .) and uses only med ica l <br />gases . <br />DC . Th is business operates a farm for purposes of cultivating the soil , raising , or harvesting an <br />agricultural or horticultural commodity. <br />Q3. DYes ¢Jo Does your bus iness handle an acutely hazardous material? See definition on reverse side of this <br />form . <br />Q4 . DYes llaNo 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 />uts/PianningApplicatidns/Business License (Revised 02-24-15 )