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03-01-18,'10:49AM;Froln: To:4683433 ;123456 # 1/ 1 <br />San Joaquin County <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sjgov,orglehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />RECF!�,° <br />A,R 01 2018 <br />DIRECTOR <br />0bnh-a ,[�EHTAL HI <br />PROGRAM COORDINA7 <br />Ruben McClellon, REFS <br />Jeff Carruescc, REHS, ROI <br />Kasey Fo;ev, REHS <br />Linda Turkafle. REHS <br />Rodney Estrada, REHS <br />Adrienne Ellsaesser. REHS <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />business Name: JY1 Telephone: -1 2- f 6,A l <br />Business Site Address: t1lfR+ UG I p�'� `5a <br />Mailing Address (if different from above): r--� <br />Business Owner(s) Name: lephone: <br />Business Owner Address, <br />Nature of Business: M G.AA . 0 rAu ort n A Pire District: CXA-,Z�Y—, <br />Q1. 1Yes ❑ No Does your business handle a hazardous material in any quantity of any one time in the <br />I year? See the definition of hazardous material on page 2 of this form, <br />i <br />Yes o No Does your business generate, treat, or store a hazardous waste in )nv quantity? (used oil, <br />used antifreeze, waste solvent, eto,) <br />If your answer is "No" to both questions In 01, pleaso print, sign, and date the bottom of this form and return to the address above. <br />Q2, ❑ Yes 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 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 />n A. 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 />[111 <br />ublic.❑B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity, <br />03, o Yes No Does your business handle an Acutely Hazardous Material? See definition on page 2, <br />04. ❑ Yes No Is your business within 1,000 feet of the outer boundary of a school? (Gradas 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 (NSC). i understand that if I awn a facility or property that is used by tenants, 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. I j <br />declare under the penalty of perjury that the Information provided on this disclosure survey is true and accurate to the best of <br />my knowledge. <br />Owner or Authorized Agent: 1 <br />Print Name: �G. Date: <br />Signature: Title: VtC--. 2 re's I66.U+ <br />1 <br />i <br />