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FF-, v C-� z G gC1cl <br />SAN 10AQUIN <br />COUNTY <br />Environmental Health <br />*rer <br />t <br />PR � 6 <br />Rp <br />HAZARDOUS MATERIALS DISCLOSURE S p�RMFR�NT <br />URVEY <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: �1 '' CnY►r, ,/� J1k?-"j el phone: 2,o <br />Business Site Address: l ��,Lr / C� �W , - - - �-I— <br />Mailing Address (if different from above) <br />Business Owner(s) Name:�l?t) kAV1h 1,21,% 6, Gt h) ;�' Telephone: , 12) <br />Business Owner Address: <br />Nature of Business: D-01'►Fire District: <br />Q1. e>(es ❑ No 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 />FyYes ❑ No 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 both questions in Q1, please print, sign, and date the bottom of this form and return to the address above. <br />Q2. �es ❑ No 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 />❑ A. 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. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. D4es ❑ No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. oV.,Yes ❑ No 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.calepa.ca.gov to submit your hazardous materials information. <br />Owner or Authorized Agent: � r <br />Print Name: �i'�y 4^ ` ` �1��M ? L� \ 1 i ✓ Date: ti I > <br />Signature: Title: (t , L '� L'l <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />