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From 5105629002 1.510.562.9002 Sat Jan 27 12:06:15 2018 MST Pa <br />h ECV,E 117D <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 />IAM 2 9 2018 <br />DIRE-CgRONMENTAL HEALTH <br />Donna Heran0FRARTMENT <br />PROGRAM COORDINATORS <br />Robert McOellon. REHS <br />Jeff Carruescj), REHS, RDI <br />Ka;ey Foley. REHS <br />Linda Tuikalte. REHS <br />Rodney Estrada, REHS <br />Adrienne Ellsaassar, 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 />A C' rV--t C_ t c � - ~ 1e3 - C { I �� 41 "' <br />Business Name.' Telephone' <br />Business Site Address: <br />C <br />0157Z. I -j— <br />Mailing Address (if different from above): <br />Business owner(s) Name:Telephone: 2t"2 <br />Business Owner Address: �� r1 � v���, r~ ^-t C <br />Nature of Business: IJT7AC j fre District: ock . <br />Q1. p!es 0 No Does your business handle a hazardous material in any quantity at any one time in the <br />year? See the definition of hazardous materlal on page 2 of this form. <br />�4 es G, 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 01, please print, slgn, and date the bottom of this form and return to the address above. <br />02. )ai7-Yes o No Does your business handle a hazardous materlal, 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 tong 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 />C) 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 >F:�)o Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />04. Yes o 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 (HSC). I understand that If I own a facility or properly 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 AgenL <br />Print Name: A G ( Date: _ i L A ` <br />Signature: Title: <br />RD- e9 1 110711 2 <br />