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®O <br />Page 1 of -2 <br />■ <br />k.. <br />2018-01-15 21:57:10 (GMT) <br />19162440197 From: Dan Ordoins <br />ED <br />TT R. <br />/may ` qq S v� . t cr l � rL"'UA. Al C c#r .'N T r ❑ ` �7 ry NN \ `�y' <br />l856 A.vsnu,�. Stor.Vtpn. CA O5,' 54-34, <br />TEIs,_t�.00e (20'1 d88-3-420 Fax lzcll), 464-0138 16 A19 <br />�:,•, , eE,.m <br />EAI R0NM+_N'TAL VEALTH <br />PE11MIT/SERMI CES <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate surveyfom is required far eah business name andlor address in San Joaquin County, <br />Business Name'Yrol RQrk i^. �„* Telephone: . -1 % r <br />13389 Folsom Blvd #340.145 <br />Bus'nes`s Site Addra:ss: <br />Mailing Address (if different from ekvp): �,_ode* <br />Business. Uwne a gene: Q 1'A n, Tefeoone;I Cw <br />BL*ness Owner Address: 1 ! (dal +Pic, .rcl co A c--+. t2 is •-� dl 3� 3 V <br />Nariure QF 8usirless: i r, r:.� - �'.�S. o. t f Fire District <br />01. o.Yes z ;mss your business handle a hazardous material in ary ouartity at any sine firm In the <br />year? See the definition of hazardous mataAal on page 2 of this Berm, <br />oYes o toes yoar business generate, treat, or store a hazardous +waste ig any guentitf? (used o(l, <br />used antifreeze, -waste solvent etc..) <br />If yow ar er is "No" to.both questions in 011, pteaft print, sign, and plate the:bgttdrlr;of ,film tsar and return to the addms above. <br />02- a Yes l o Does your business handle a hazardous .material, & a mixture containing . a hazardous <br />material, in a quantity equal to or greater than 55 galions, 500 pounds, or 200 cubic feet at <br />any one time in the year? <br />If 'Yes', how long have you haMlecd.:these nmatodal$ :at yow business? <br />If''Yee, check. any of the `olloWng :conc9lions that apply to your business: <br />c A. The hazardous materials handled by this business are contained solely in a consumer <br />product packaged for direct distrfbulion t/a and use by the general public <br />08. This bur;mess operates a farm for purposes of aftvatincg the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />0i a Yens Does your business handle an Acutely. Hazardous MaterlaP See definitiort.an page 2. <br />04, c 'Yes � Lf14o is your business within 1,000 feet ofd outer boundary of a school? (Grades M-12) <br />I have read the information on this form and understand my requirements under Chapter6.95 of the California Wealth and Safety <br />Code (HSC). I understand that 0 t own a facility or property that is used by tenants, it Is my responsibility to notify the tenants of <br />the requirements which gnus; be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under <br />the penalty .of .psrjtuy that the .iriformat",.provided on thts.disclosurs survey is true and accurate to #ire test of my knowledge: <br />if you answer9d mfse to Quesdon Z; *ase go online to cers_cattpa.;.a,.coy V) subrr* your hazardous rr ateerots information, <br />Owner or Authorized Agent: <br />Print dame: 3 L.x` t f Date: — L l 4.. . tw <br />Signature: ! 'l G ti f i" Titfe: Qc v1. -t f <br />Xo� stack Contra" <br />13369 olsom Blvd *300-146 <br />EtID tg t?2 HMP SUR'R'EY <br />rtr;Msed $25116 <br />t•a O' o,+.�,rI Sellne Pud uui POP03 dbZ:LO $t C1 uer <br />Received Time Jan, 15. 2018 1:51PM� No, 2900 <br />