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ECC NI r San Joaquin County Dltt�,cTaR -, 2017 �Q Environmental Health Deparbiumt DonnaHenan, REH3 M1C�ilr[ a� 1868 E f iiazlefton Avenue PROGRAM COORDINATORS Stockton, California gJ�0J� RobertMcClellon,REHS Jeff Carruesco, REHS, RDI Kase <fkpa��r Wabsite: www.sjgov.org/ehd Linda Turk Foley, REHS Phone: (209) 468-3420 Rodney Estrada, REHS Fax: (209) 468-3433 Adrienne Ellsaesser, REHS HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required For each business name and/or address in San Joaquin County. Business Name: Business Site Address: Mailing Address (if different from above): Business Owner(s) Name:—�-011 LL Telephone: (, a� �Lq % I i 1S Business Owner Address: "K21U-1—XV-TWU F'�AUA—r ya . Nature of Business: L—k Qj�-- i A Fire District: 1 Q1. Xyes o No Does your business handle a hazardous material in any quantity at any one time in the year? See the definition of hazardous material on page 2 of this form. u Yes �No Does your business generate, treat, or store a hazardous waste in any quantity? (used oil, used antifreeze, waste solvent, etc.) 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. Q2. Yes ri No Does your business handle a hazardous material, or a mixture containing a hazardous material, in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time in the year? If "Yes", how long have you handled these materials at your business? If "Yes", check any of the following conditions that apply to your business: A. The hazardous materials handled by this business are contained solely in a consumer product packaged for direct distribution to and use by the general public. o B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an agricultural or horticultural commodity. Q3. a Yes No Does your business handle an Acutely Hazardous Material? See definition on page 2. 04. ❑ Yes No Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12) I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety Code (HSC). I understand that if 1 own a facility or property that is used by tenants, it is my responsibility to notify the tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owner or Authorized Agent: Print ��`R1Y10. Date: Name: Signature: Title: \, 1l_. a Revl ad 1110712