Laserfiche WebLink
San Joaquin County <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sjgov.org/ehd <br />Phone (209) 468 3420 <br />ritutIVED <br />NOV 0 4 2M <br />DIRECTOR <br />EWRQNWNTAL <br />PhlFSM OMWRARM <br />Robert McClellon, REHS <br />Jeff Canuesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, REHS <br />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 />B g(k Name: �ILL�,� `%� �i/fes/aC�%cW Telephone: <br />Q ness Site Address: 1112 R4C/,/k� 0 Aelllc— <br />Tvlailing Address (if different from above): 530 V& ✓0 0 <br />Business Owner(s) Name: PO4, 6 k' M* e T,uC . Telephone: l 7�s- qt J 3L /— <br />Business Owner Address: Q0 OL ✓d <br />Nature of Business: %i9L Li/.L' % C -.c ` V1fi - _ /✓C. Fire District: Cl?y 0' <br />Q1. c Yes 'No <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 />c Yes � o <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 Q1, please print, sign, and date the bottom of this form and return to the address above. <br />Q2. - Yes c 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 />cA. <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 />c B. <br />This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. c Yes c No <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. c Yes c No <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 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 />Owner or Authorized Agent: <br />Print Name: U i cJ &,P. Date: <br />Signature: Title: <br />Rev dllN1/12 <br />// -0 C • /r— <br />E,`Z074/&Xe O/1�- ,PGL 07L-0 <br />I<x-4::A5� <br />