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• <br />• <br />• <br />COUNTY OF SAN JOAQUIN <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton , California 95205 <br />Telephone (209) 468'-3420 <br />FAX (209 ) 468-3433 <br />Website : www .sj gov.org /ehd <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />0 <br />Please read the information on the reverse side before comp leting this survey form . <br />name and/or address in San Joaquin County is required . <br />A separate survey for each business . . <br />01 . <br />Business <br />Name : <br />Or 1\(.,j, mGn GI.l e(' = :Tc:r SOf'\ 201-t/2.3 -Z /S I <br />~oiU.,..... M «.rk tt1cll'\,-'nfl Telephone : ~?9-7BS-booo(r) <br />Business <br />Address : <br />Mailing Address (if different from <br />above): <br />S+ec.Jc:+o, UJ qsz.qS <br />Roe.J, futtl ..s mi¥. d-A ?2917 -ooYS <br />Nature of f <br />Business : kucJLJ"--lG ~ ():rsre.:r'\3 U!t ~1\.J Qp6fli1 11;t>.!Fire District: MOY"vt -G UtJrV\ .. C-\_. <br />rfves DNa Does your bus iness handle a hazardous material in any quantity at any one time in the year? See the <br />definition of hazardous material on the back of this form . If your answer is No,' go to Question 4. <br />02 . ~es DNa Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br />quantity equal to or greater than 55 gallons, 500 pounds , or 200cub ic feet at any one time in the year? <br />If "Yes ," how long have you handled these materials at your business? / ?7 2 <br />If "Yes ," checl< any of the following conditions that applies to your business . <br />DA. The hazardous materials hand led by th is bus iness Is conta in ed solely In a consumer product , <br />packaged for direct d istr ibution to, and use by , the general pub li c . <br />DB . This business Is a health care facility (doctor, dentist, veterinary, etc.) and uses QD.ly med ical <br />gases . <br />DC. This business operates a farm for purposes of cultivating the soil , ra ising, or harvesting an <br />agricultural or horticultural commodity . <br />03. fives ONo Does your business handle an acutely hazardous material? See de finition on reverse side of this <br />form. <br />-Q4 . DYes i511'No Is your business within 1,000 feet of the outer boundary of a school (grades K-12)7 <br />I have read the information on this form and understand· my requirements under Chapter 6.95 of the California Health and <br />Safety Code . I understand that if I own a facility or property that is used by tenants, that 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 operat ions . <br />I declare under the penalty of perjury that the information provided on this disclosure survey Is true and accurate to the <br />best of my l<nowledge . <br />F/AppllcatlonsForms&Hando.uts/PiannlngAppllcatlons/Bus iness License (Revised 02-24-15 ) <br />Page 4 of 6