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RECEIVED <br />JAN 0 4 2016 <br />San Joaquin County ENVIRO�NMENTR HE HEALTH <br />Environmental Health DepaAF eOR <br />nIT1SDonna Heran, REHS <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, 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: 7 u I C �` <br />aLl 1 e ' ` u (_ Telephone: <br />Business Site Address: Z �P <br />hslf� C YAtt'C-k 'Ef-C— VA �� R <br />Mailing Address (if different from above): <br />Business Owner(s) Name: {� <br />c� k W n Telephone: <br />Business Owner Address: �- <br />� S2 <br />���k S} �r 1 lt C � W) <br />Nature of Business: P1 1.\c <br />:2 Fire District: 4,0�0 <br />Q1. (Yes ❑ No <br />business material any one time in the <br />this quantity <br />Does your <br />2 form, <br />definit definitionhandle <br />See the hazardous material onpage of <br />VYes ❑ No <br />Does your business generale, 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. o Yes t No <br />Does a hazardous material, or a mixture ng a hazardous <br />business l to or than 55 gallons, 500 pounds, or'200 cubic feet at <br />in <br />equar greater <br />material, a quantity <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 />o A. <br />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 />o B. <br />This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. ❑ Yes XNo <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4, o Yes _ jf`No <br />Isyourbusiness 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: # D K r r �T I Y Date: <br />Signature: "� Title: <br />