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F'N\ <br />RECEIVED <br />JAN 12 2018 <br />N' tea'■ 1 ��.:<'', <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, 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: SSU KRQ C O U'R(j ili-E T Ub 1111 L SLUC • Telephone: 9l0� -33w - 5 000 <br />Business Site Address: Wly S L h1 E R O jKL E LANF L G i7,1 ( f 1 %:)M C, <br />Mailing Address (if different from above): 0%K)5 (fii-zRcKEf: LANE LQ)()! (n g5` L10 <br />Business Owner(s) Name: RI L ACO SF1tJ AOR �' Telephone: 'QlC� 334- 5GCC1 <br />Business Owner Address: (A I G S C H €R0 K£ -E L A1Nt LO I)L ( A 9 5 ay c) <br />Nature of Business: K W ( GLS 01ETAI L W ( Lo 10- Fire District: (- I TY 0�' L%Qz <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 ❑ No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. ❑ Yes ❑ No Is your business within 1,000 feet of the outer boundary of a school? (Grades K -t 2) <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: R R1 63 S( -W fy) I fl I Date: 1018 <br />Signature: ✓f Title: liVNY FOQ 0WW7ER <br />Revised 11/07/12 <br />