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to <br />RECEIVED <br />MAY 18 2018 San Joaquin County <br />its p DIRECTOR <br />N <br />ironmental Health Department Donna Heran, REHS <br />0NMENTAL H1 <br />P�FMMSERWCES 1868 E Hazelton Avenue PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Stockton, California 95205 <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />WEbYV <br />51t@: WW.sjgov.orgJehd Linda Turkatte, REHS <br />Phone: (209) 468-3420 Rodney Estrada, RENS <br />Fax: (209) 468-3433 Adrienne Ellsaesser, RENS <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey <br />form is required for each business name and/or address in San Joaquin County. <br />Date: <br />aA <br />�- (Q <br />20� 3Co-Lo 3 <br />` - \ Telep ne: — <br />Business Name: <br />Business Site Address: <br />- v <br />Mailing Address (if different from above): <br />Business Owner(s) Name: _S,Q�VLe..,zAk's—� <br />Telephone:.�� <br />Business Owner Address: <br />Nv_ <br />Nature of Business: C� <br />1�- Fire District: Lx(Ai <br />Q1. a 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 />Li Yes s�No <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. r.: Yes a 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 />u A. <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 />❑ B. <br />This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or l or acultural commodity. <br />Q3. n Yes c No <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. u Yes ❑ 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. 1 <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: <br />�G <br />Date: <br />Signature: <br />Title: <br />