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PRO 52o -T13 11 u5V5 <br />San Joaquin County <br />DIRECTOR <br />Environmental Health Department Donna Heran, REHS <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sigov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, RENS, RDI <br />Kasey Foley, REHS <br />6iad� rk8tte, REHS <br />r�ey , da '}fijS� "� <br />4a� MAY 0 6 2016 <br />=HAZARDOUS MATERIALS DISCLOSURE SUR <br />1VEl(�,�,� <br />Gp Ce <br />A separate survey form is required for each usiness name and/or add <br />s in San Joag0jvCouflty ,,,.; <br />2� G W P W_6L�? <br />Q HOLT OF CALIFORNIA / ELECTRIC GUARD DOG 803-404-6189 <br />Business Name: Telephone: <br />Business Site Address: 1521 W CHARTER WAY <br />Mailing Address (if different from above): <br />Business Owner(s) Name: KEN MONROE <br />Business Owner Address: SAME AS ABOVE <br />Telephone: 209-461-7890 <br />Nature of Business: CONSTRUCTION EQUIPMENT RENTAL & SALES Fire District: STOCKTON <br />(THIS IS FOR THE INSTALLATION OF A SECURITY FENCE AND THE BELOW <br />ITEMS DO NOT APPLY TO THIS PARTICULAR DETAIL) <br />Q1. ❑ Yes � No Does your business handle a hazardous material in any quantity at any one time in the <br />year? See the definition of hazardous material on page 2 of this form. <br />❑ Yes � No Does your business generate, treat, or store a hazardous waste in any quantity? (used oil, <br />used antifreeze, waste solvent, etc.) <br />If your answer is "No" to both questions in Q1, please 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 />❑ 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 />❑ B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. ❑ Yes VNo Does your business handle an Acutely Hazardous Material? See definition on page 2 <br />Q4. ❑ Yes N 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 (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 met prior to issuance of a Certificate of Occupancy or beginning of operations. I <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: <br />Print Name: Cf/R9L BAUSIGNER Date: 10/28/15 <br />COMPLIANCE MGR/EGD <br />Signature: Title: <br />1 <br />Revised 11/07/12 <br />