Laserfiche WebLink
JUN/27/2017/TUE 07:01 AM <br />FAX No, <br />San Joaquin County <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Websita: w .sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468.3433 <br />JUN 27 2017 <br />714TAL HEALTH <br />DIRECTOR r-- IT <br />Donna Heran, RENS <br />PROGRAM COORDINATORS <br />Robert McClellan, REHS <br />Jeff Canuesco. REHS, RDI <br />Kasey Foley, RENS <br />Linda Turkatte, REBS <br />Rodney Estrada, RENS <br />Adrienne Elisaasser, 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 />Business Name: Walman <br />Business Site Address: 10355 Trinity Parkway Stockton, CA <br />Mailing Address (lt different from above): <br />Telephone: <br />Business Owner(s) Name: <br />Walmart REBT Telephone: 479-204-2524 <br />Business Owner Address: <br />2001 BE 10th Street, Mail Stop 5520 Bentonville, AR 72716 <br />Nature of Business: Mercantile Fire District: Stockton <br />Q1, x Yes o No <br />Does your business handle a hazardous material In any ouantky at any one time in the <br />year? See the definition of hazardous material on page 2 of this form. <br />K Yes o No <br />Does your business generate, treat, or store a hazardous waste in ani an? (used oil, <br />used antifreeze, waste solvent, eta) <br />If your answar is "Noe to both <br />questions in 01, please print, sign, and date the bottom of this form and return to the address above, <br />Q2. ❑ 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 />m 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 />o B. <br />This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity - <br />Q3, o Yes r� No <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. ❑ Yes 6 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, Ster3hanie Whorton. Owner Agent Date; 08.21.2017 <br />sew@bgark.com <br />Title Senior Permitting Specialist I Owner Agent <br />earmau,wrns <br />