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�■�EC/16/2016/FRI 11:30 AM COMMUNITY DEVELOPMEN FAX No,12099378893 P,001/001 <br />■ <br />■;■ U53� O05 , T U r3�35rJ <br />■ <br />UIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT�v�'��® <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone (209) 468-3420 Fax (209) 464-0138 DEC 16 2016 <br />www.sjcehd.com ENVIRQ-NMENiAL HEALTH <br />PERMIPSERMES <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address In San Joaquin County. <br />Buslness Name: Safeway #1769 Telephone: 209-461-5555 <br />Business Site Address: 2808 Country Club Blvd., Stockton, CA <br />Mailing Address (if different from above): <br />Business Ownar(s) Name: _Nicholas Sbeno (Trustee) Telephone: <br />Business Owner Address 1371 Oakland Blvd, Suite 200, Walnut Creck CA 94596 <br />Nature of Business: Grocery Store Fire District: <br />Q1. o Yes r4o 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 Flo 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 01, please print, sign, and date the bottom of this form and return to the address above. <br />Q2. o Yes AQ 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 />od 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 />n 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 /0110 Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. ❑ Yes c 40 Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12) <br />1 have read the information on this form and understand my requirements under Chapter 6,95 of the California Health and Safety <br />Code (HSC). I understand that if I own a facility or property that is used by tenants, it is my responsibility to notify the tenants of <br />the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under <br />the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br />If you answered "Yes" to Question 2, please go online to cers,calepa.ca,goy to submit your hazardous materials Information. <br />Owner or Authorized Agent: <br />Print Name: Debi Plaisance 407-643-2347 DebiP@c-p.com Date: <br />Signat e: Title: <br />EHD 19-02 <br />Reviaed 8125118 <br />Received Tlme Dec,16, 2016 10:21AM No.0514 <br />i <br />Permitting Coordinator <br />HMBP SURVEY <br />