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„rN San Joaquin County <br /> oP.4 c DIRECTOR <br /> Environmental Health Department Donna Heran,REHS <br /> � Z <br /> 4 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> : Stockton, California 95205 Robert McClellon,REHS <br /> Jeff Carruesco,REHS,RDI <br /> o Q Kasey Foley,REHS <br /> Website: www.sjgov.org/ehd Linda Turkatte,REHS <br /> Phone: (209)468-3420 Rodney Estrada,REHS <br /> Fax: (209)468-3433 Adrienne Ellsaesser,REHS <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: YA N 1)AQWE5S Telephone: <br /> Business Site Address: '(�11/ Nl�,�.� I2� ,5?1— Z F <br /> Mailing Address(if different from above): <br /> Business Owner(s) Name:` ,�►rDA EST 2 _"yP Telephone: �-n lf9 <br /> Business Owner Addree�ss�l <br /> Nature of Business: er 1 kv`k�4 Fire District:- V kAC Y <br /> Q1. Wes ❑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 /> ❑Yes oo o 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. 9-Yes ❑ 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? E� / <br /> If"Yes", how long have you handled these materials at your business? 6-<5 9CZ23 <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 <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 commodity. <br /> Q3. ❑Yes Ao Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes �10 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 requiremehts under Chapter 6.95 of the California 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 /> �aw;uA­�"ct- � w�oVE'_c�a-�pG.,nc�a( . Love\ <br /> Owner or Authorized Agent: 1 <br /> Print Name: J '_\ SWA Date: <br /> Signature: Title: <br /> 1 <br />