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P"'ECE! VED <br />G 1�259q16 11 <br />k.*AV 0 y 2018 <br />ENMONP ENTIAL <br />H �ITH nr:r)apTl1"nFNT <br />San Joaquin County <br />Does your business handle a hazardous material, or a mixture containing a hazardous <br />_ <br />Environmental Health Department <br />DIRECTOR <br />Donna Heran, REHS <br />1868 E Hazelton Avenue <br />ORS <br />- StCalifornia 95205 <br />k be M^cCillon,, REFIS <br />ockton, <br />Jeff S, RDI <br />aFoley, <br />o A <br />KaseyRENS <br />Website: www.sjgov.org/ehd <br />Linda Turkatte, RENS <br />Phone: (209) 468-3420 <br />Rodney Estrada, RENS <br />Fax: (209) 468-3433 <br />Adrienne Ellsaesser, RENS <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: 1^1 <br />Business Site Address <br />Mailing Address (if different from above): <br />Telephone: <br />Business Owner(s) Name: 7A -4t iT %RWr<IN f Telephone: <br />Business Owner Address: 1000 #j1em Xr A04A-, I�tr✓✓ �W fj MA! i� <br />Nature of Business: -Act"- Fire District: L <br />(�a�t rte u kvvt RA-%W,-6,L'J <br />4N < R?dr� <br />Q1 n Yes No Does your business handle a hazardous material in an v N a inv at any one time in the <br />k year? See the definition of hazardous material on page 2 of this form 11111 -vv/ AN -S <br />u Yes W Does your business generate, treat, or store a hazardous waste in any quantity? (used oil, S <br />used antifreeze, waste solvent, etc.) <br />If your answer is "No" to both questions In 01, please print, sign, and date the bottom of this form and return to the address above <br />Q2. o Yes o No <br />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 />Ill"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 <br />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. <br />This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. u Yes u No <br />Does your business handle an Acutely Hazardous Material? See definition on page 2 <br />Q4 o Yes u 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 Cal'rfomia Health 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: "� f DateIf <br />/ <br />Signature <br />R- I'MY" 2 <br />