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Pp- 05c(05G2- lems -0 / oo / <br />San Joaquin County <br />DIRECTOR <br />Environmental Health Department Donna Heran, REHS <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 />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />r--Hnda-;Fu&atte;-REHS q r� <br />R�odrney;iLstrada- REHS '�� <br />ASrfe Ellsaesse°r. REI- s <br />r IPP 12 L, ,J <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY ENVIRONMENTAL <br />A separate survey form is required for each business name and/or address in San Joaqu1-&T#.DE=PARTMENT <br />Business Name: 67'14gT 'Roo -rP4�5f.o 1,1G c0 Telephone: -7(, I — Z 417 <br />Business Site Address: ko �VA1 n St <br />Mailing Address (if different from above): <br />Business Owner(s) Name: F3Ek-ol,LJC P-4F—T+-I cS, LL&Telephone: 22ec�• X69• 2L-7&_ <br />Business Owner Address: 110 k/ S;,J-AY JC4,�2U ltj S_rP. <br />Nature of Business: f2� STq U 2,47.17 Fire District: <br />Q1. ❑ 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 /No 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. c 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. c 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. 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: J0+4J 6 u 1' -� Date: <br />3�1-7A20/6 <br />Signature: Title: <br />1 <br />Revised 11107112 <br />