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y rn COUNTY OF SAN JOAQUIN <br />''��'?� ®ECEIVE®FFTCEOFEMERGENCY SERVICES RONALD E.BALDWIN <br />fist v ` Room 610, Courthouse DIRECTOR OF <br />MAY 0 5 20117 222 East Weber Avenue EMERGENCY OPERATIONS <br />"3R"}i�� <br />Stockton, California 95202 <br />ENVIRONMENTAL HEALTH Telephone (209) 468-3962 7 <br />PERMITISERIACESIazardous Materials Division (209) 468-3969 S Z <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <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: Parkwood Cleaners <br />Business Owners) Name: JefKitto Telephone: 209-e09-2540 <br />Business Address: 1901 country Club Blvd, Stockton, CA 95204 <br />Mailing Address (if different from above): <br />Nature of Business: Retail Laundry and dry cleaning Fire District: Stockton <br />Ql. ©Yes GNo Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br />of hazardous material on the back of this form. If your answer is No," go to Question 4. <br />Q2. 9Yes ONo 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 200cubic feet at any one time in the year? <br />If "Yes," how long have you handled these materials at your business? 11 YEARS <br />If "Yes," check any of the following conditions that applies to your business. <br />IIA. The hazardous materials handled by this business is contained solely in a consumer product, packaged for direct <br />distribution to, and use by, the general public. <br />OB. This business is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical gases. <br />IVC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br />horticultural commodity. <br />Q3. DYes f1No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br />Q4. [[Yes SNo 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 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: <br />X Michael Glavin Date: 4;24x2017 <br />Print Name <br />X Title: <br />.� <br />Signature <br />F:\Devsys\Planning Application Forms Page 1 of 2 <br />Hazardous Materials Disclosure Survey (Revised 8-25-03) <br />