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T1Zu5i,��,' 0Se2 <br />San Joaquin County <br />Environmental Health Department <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 />RECEIVED <br />JUN 13 2018 <br />E RikNI4&,"EALTH <br />RAMIT/SEf��gg <br />PROGM Nl &S <br />Robert MCClellon. REHS <br />Jeff Canuesco. REHS. RDI <br />Kasey Foley, REHS <br />Linda Turkalte, REHS <br />Rodney Estrada. REHS <br />Adrienne Ellssesser, 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: C-4''fT4 9—' L%,d' 1 Telephone: <br />Business Site Address: "101?::� 1 5i � Ez QI2 r=h <br />Melling Address (if different from above): <br />Business Owner(s) Name: W Telephone: <br />Business Owner Address: <br />Nature of Business: Fire District: <br />Q1. o Yes Does your business handle a hazardous material in any cuantity at any one time In the <br />year? See the definition of hazardous material on page 2 of this form. <br />❑ Yes ❑ N Does your business generate, treat, or store a, hazardous waste In any quantity 7 (used oil, <br />used antifreeze, waste solvent, etc.) <br />If your answer is "No" to both questions In Q1, please print, slgn, 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 65 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 />o 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 />o B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. o Yes o No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. ❑ Yes u 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 />Safely 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 Nam <br />Signature: <br />Name <br />H Wtwat] <br />Date: <br />TIUe: <br />