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RECEIVED <br />APR 12 2016 <br />a ti <br />San Joaquin County EWRQWRU#LHEALTH <br />°a Environmental Health Department PERW"Xr#Fffi0PkaS <br />2 'G <br />1868 E Hazelton Avenue PROGRAM COORDINATORS <br />Stockton, California 95205 Robert McClellon,REHS <br />Jeff Carruesco, RENS, RDI <br />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 />�eJe�°p�RDOUS MATERIALS DISCLOSURE SURVEY <br />e� arate survey form is required for each business name and/or address in San Joaquin County. <br />GO�� <br />Pe$usin ss Name: �c pp o <br />Business Site Address: <br />Mailing Address (if different from above): ' 'i© I') U 7- oL LA �p l—h j( i "C ('A C� `) r3 <br />Business Owner(s) Name: �A N)l �CP,- S i (\i(A 1 Telephone: � '9, 1 '' G I a (� <br />Business Owner Address: Il l��i C) oLDc J 5 P ILE ` r R NL . LA'rti P�oP, r 533D <br />Nature of Business: Fire District: <br />Q1. ❑ Yes X o <br />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 lo <br />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 <br />in Q1, please print, sign, and date the bottom of this form and return to the address above. <br />02. ❑ Yes Vlo <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 />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. <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. ❑ Yes )<-No <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. ❑ Yes Volo <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 California Health and <br />Safety Code (HSC). I understand that if I own a facility or property that is used by tenants, it is r4y 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: P\�� 07� (Z 1 Date: <br />Signature:Title: t) LA E y— <br />Revised 71/07/12 J& <br />-0191/45 <br />