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I <br />San Joaquin County 10 <br />DIRECTOR <br />Environmental Health Department Donna Heran, REHS <br />1868 E Hazelton Avenue PROGRAM COORDINATORS <br />Stockton, California 95205 <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <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 />ENVIRONMENTAL HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />HEALTH DEPARTMENT <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: o ' SES-12ET Telephone: lP 14. L-1 IS •��° i) <br />Business Site Address: h 3 0 °v b�L� L p�v- 1a <br />Mailing Address (if different from above): �t 1✓ Ll t-'� �'��� 1�A 1'Lk-w &NLwP�q" b lam} <br />Business Owner(s) Name: Telephone: (.o t`4 . ►-( 1G. tb 0 0 <br />Business Owner Address: -_CVAY)-0a 1.tt-i��(A� 1p A k2_Ic.w �✓1 t GD LL-, "('K ,_\ , o <br />Nature of Business: Fire District: <br />Q1. ❑ Yes Ao 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 A0 Does your business generate, treat, or store a hazardous waste in any ouantity? (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 ❑ 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? <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 ❑ No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. ❑ Yes ❑ 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 <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. <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: ma l 1/�lik-tiS Date: LA • L't a <br />Signature: Title: &>Q TtwZ <br />Revised 11/07/12 <br />