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RCIE, <br />, <br />Mo ,5) -G --H I <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 />DIRECTOR <br />Donna Heran, REHS <br />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, REHS <br />Rodney Estrada, REHS <br />Adrienne Ellsaesser, REHS <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />ENVI30NMENT . <br />� ,A separate survey form is required for each business narne and/or address in San Joaquin County. <br />HEaLTa i C�'= <br />Business Name: NIMT-t`b�S &SINVAMT Telephone: <br />Business Site Address: 7 (/J A}F'lKv?-- (,l Kv , ��OLiLTUI� cA 15-7- 11 <br />Mailing Address (if different from above): Iry ' 0 -6p(yl� as,& f JTE, ZOO eL- Gyp <br />Business Owner(s) Name: /�T C�� HA171gSGp Tele hone: Sl0-ZT 1 1:1 S-1 <br />Business Owner Address: kC— ►�f7pQ-SSS --3 <br />Nature of Business: NT <br />Fire District: <br />01. r Yes )i(No Does your business handle a hazardous material in any quantity at any one time in the <br />year? See the definition of hazardous material on page 2 of this form. <br />o Yes X 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 Q1, please print, sign, and date the bottom of this form and return to the address above. <br />Q2. a Yes ii No Does your business handle a hazardous material, 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 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 />B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural :;ommodity. <br />Q3. Yes i_i No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. n Yes ,_r No Is your business within 1,000 feet of the outer boundary of a school'? (Grades K-12) <br />E have read the information on this form and understand my requirements under Chapter 6.95 of the California Heait'r, and <br />Safety 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 Name: z' pt�—, V-) '! t� l�/1v Date <br />,2s:�7 <br />Signature: Title: <br />Revised 11/07/12 <br />31z�1 <br />AwmT � ;—r-syEf�71� 6EN�TSV e, <br />