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MU56 (01b3j <br />COUNTY OF SAN JOAQUIN <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Telephone (209) 468-3420 <br />FAX (209) 468-3433 <br />Website: www.sjgov.org/ehd <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />RECEIVED <br />JUN 0 4 r2u,8 <br />LNVIRONNILN'I'AL IIEAUF11 <br />DEPARTNIEN'I' <br />Please read the information on the reverse side before completing this survey form. A separate survey for each business <br />name and/or address in San Joaquin County is required. <br />Business <br />Name: TSS M AR t <br />Business Owner(s) <br />Name: <br />Business <br />Address: <br />Ky o \\-\ SING \4 Telephone: 2cij— �&,6-- 1 7�'f 7 <br />Mailing Address (if different from <br />above): 0 0 3 . Lo cJet� <br />Nature of 2 <br />Business: e.yiQ (Z S W( Fire District <br />AWLAM a <br />Q1. ❑Yes �No Does your business handle a hazardous material in any quantity at any one time in the year? See the <br />definition of hazardous material on the back of this form. If your answer is No," go to Question 4. <br />Q2. ❑Yes 'K No Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br />/ quantity 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? <br />If "Yes," check any of the following conditions that applies to your business. <br />❑A. The hazardous materials handled by this business is contained solely in a consumer product, <br />packaged for direct distribution to, and use by, the general public. <br />❑B. This business is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical <br />gases. <br />❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br />agricultural or horticultural commodity. <br />Q3. ❑Yes ONo Does your business handle an acutely hazardous material? See definition on reverse side of this <br />form. <br />Q4. ❑Yes 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. I understand that if I own a facility or property that is used by tenants, that 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. <br />I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br />best of my knowledge. <br />Owner or Author gent: <br />X M ji T C t S�1G u Date: <br />Printame <br />X �7 flh6A- Title: bI 'riPt� <br />Signature <br />F/ApplicationsForm s&Hand outs/PlanningApplications/Business License (Revised 02-24-15) <br />Page 5 of 6 <br />