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SAN J O A Q U i N Environmental Health Department <br />40 N 1 2018 <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY RQ�42.4z C <br />A separate survey form is required for each business name and/or address in San Joaquin County. RLICF8 <br />Business Name: i -A Pti-e L 4 AZ V L Telephone: Z0 -1-71Z — (0 S 7 <br />Business Site Address: '�5-2 `j <br />Mailing Address (if different from above): <br />Business Owner(s) Name: W A (,(ZQ 1? 1 IJ�A/VK G. CD R) A. N Telephone: Zoy 7 12 1 042�"7 <br />Business Owner Address: <br />Nature of Business: Fire District: <br />Q1. o Yes X No <br />Does your business handle a hazardous material in any quantity at any one time in the year? <br />See the definition of hazardous material on page 2 of this form. <br />u Yes XNo <br />Does your business generate, treat, or store a hazardous waste in any quantity? (used oil, used <br />antifreeze, waste solvent, etc.) <br />If your answer is "No" to bath questions in 01, please print, sign, and date the bottom of this form and return to the address above. <br />Q2. ❑ Yes gNo <br />Does your business handle a hazardous material, or a mixture containing a hazardous material, <br />in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time <br />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 />61. <br />The hazardous materials handled by this business are contained solely in a consumer product <br />packaged for direct distribution to and use by the general public. <br />❑ B. <br />This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. ❑ Yes jKNo <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. o Yes c No <br />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 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 the <br />requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br />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.caleoa.ca.gov to submit your hazardous materials information. <br />Owner or Authorized Agent: <br />Print Name: -T-rzbaju,'ts•1- /UIa"L4?'&WeDate: <br />�j <br />Signature: 6 ,, � " Title: <br />06-07—Zef$ <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />