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��521131 f <br />IN 06 <br />• <br />qurN <br />�o4"'E�.coG <br />2.. <br />'.i4 <br />a: :1 <br /><IPOR <br />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 />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />RECEIVED <br />JUN 11 2018 <br />_NVIRONMENTAL HEALTH <br />PERMIT/SEWCES <br />Please read the information on the reverse side before completing this survey form. A separate survey for each business name <br />and/or address in San Joaquin County is required. <br />Business Name: oomfi TEL AWA VWnt✓i 666 y 6UWU j <br />Business Owner(s) Name: KI Kt J`OW'W^:L -I \ Telephone: dv• tea' -30%Business Address: 6 401 N • ?WOi�t WAsd STO1cKTOO //ypM 955X5 <br />Mailing Address (if different fro 1 above): F.D. ?;OX A51(0 <br />Nature of Business: �01 Vj C I Fire District: <br />Q1. OYes ❑ 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. 1,IYes ❑ No Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br />equal to or greater than 55 gallons, 500 pounds, or 200c 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 apply to your business. <br />A. The hazardous materials handled by this business is contained solely in a consumer product, packaged for <br />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 gases. <br />❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or . <br />horticultural commodity. <br />Q3. 1 Yes []No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br />Q4. 13Yes NQJo Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br />1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br />Code. I understand that if I own a facility or property that is used by tenants, that it is my responsibility to notify the tenants of the <br />requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br />penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br />Owner or Authorized Agent: J <br />X &-n Q / Date: i 11019, <br />Print Name r�O <br />X Title: <br />Signature <br />F:Wpplication Forms & Handouts\Building Application Cheddists\Check List Commercial Building Permit.doc (Revised 0 110 8/2 01 6) 3 of 4 <br />