Laserfiche WebLink
O .. <br />N <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />q 1868 East Hazelton Avenue, Stockton, CA 95205- 232 <br />6J Telephone (209) 468-3420 Fax (209) 464-013D�� <br />D <br />t j� D <br />DEC 05 2016 www.sjcehd.com <br />HAZARDOUS MATERIALS DISCLOSURE SYRJ�1��� <br />�1 D s4iA .v <br />A separate survey form is required for each business name and/or address imSa�i� DEP); <br />Business Name: <br />Business Site Address: <br />Mailing Address (if different from above): <br />Telephone: Ce1Z. vi, I. -[C,41 <br />Business Owner(s) Name: <br />Telephone: <br />Business Owner Address: <br />1 ` ���i <br />-7601 ki!+ 1141, �� '. M I-".��-T <br />i 2.5 <br />Nature of Business: cl:y <br />ere w., F1.1Wt I Fire District: <br />Qt. ❑ Yeslo <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 />o Yes KNo <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 in 01, please print, sign, and date the bottom of this form and return to the address above. <br />Q2. ❑ Yes ❑ No <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. 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 o No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. ❑ Yes o 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 <br />the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under <br />the 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.caleoa.ca.gov to submit your hazardous materials information. <br />Owner or Authorized Agent: <br />Print Name <br />Signature: <br />iAw - 1'1 t 2s)t(p <br />EHD 19-02 1 (0 MOOT �VV """ � HMBP SURVEY <br />Revised 8/25/16 <br />