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RECEIVED, <br />JAI' 0 8 2016 <br />San Joaquin Caq41 <br />Environmental HealthA"tH <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />DIRECTOR <br />Donna Heran, REHS <br />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, REHS <br />Rodney Estrada, REHS <br />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: WC- Ill 2q OUrler Telephone: 5'%®'7Qy—Z97, <br />J — - . r r _ <br />Business Site Address: <br />Mailing Address (if different from above):SQ570 kJoLliS + t-Mgi tV ILL& CA � cl(oC�17� _ <br />BusinessOwner(s) Name:t.0IL4 i A M � 51,4A9,0J0 R> S0A) Telephone: 21 C) i'q8� %SSS <br />Business Owner Address: Z�Z0 LOALSM •A O, 5 -- F <br />Nature of Business: _ "LeJ2.q 1-�y1og(- Fire District: <br />01. Yes ❑ 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 gNo 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. ❑ Yes N60 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. 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 CKNo Does your business handle an Acutely Hazardous Material? See definition on page 2 <br />Q4. ❑ Yes 04U0 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 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: Date: <br />Signature: Title: <br />Revised 11/07/12 <br />-) _ l s - <br />