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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 />Fax: (209)468-3433 <br />DIRECTOR <br />Donna Heran, REHS <br />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, REHS <br />Rodney Estrada, REHS <br />JECEIVED <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY AUG 11 2015 <br />A separate survey form is required for each business name and/or address in San Jot-11WINNMENTAL <br />168-929-01 Ancillary Bldg. I Occupancy Recertification Project Ia��'Tu CD90T(�C�IT <br />Business Name: Kaiser Permanente Stockton Telephone: 209-476-2000 <br />Business Site Address: 7373 West Lane, Stockton, CA 95210 <br />Mailing Address (if different from above): <br />Business Owner(s) Name: Kaiser Foundation Hospital Telephone: 510-271-5800 <br />Business owner Address: One Kaiser Plaza, Oakland, CA 94612 <br />Nature of Business: Healthcare Fire District: N/A <br />Q1. )p Yes ❑ No Does your business handle a hazardous material in any quantity at any onetime in the <br />year? See the definition of hazardous material on page 2 of this form. <br />p 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 Ot, please print, sign, and date the bottom of this form and return to the address above. <br />02. p 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? 7 Years <br />If "Yes", check any of the following conditions that apply to your business: <br />o 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 />D B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. X Yes o No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />04. ❑ Yes il( 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 ttlat,,the information provided on this disclosure survey is true and accurate to the best of <br />m knowledge. Y 9 d <br />Owner or Authorized Agent 141 7 L.O1J <br />Print Name: Tonia Shaw J Date: 04-09-15 <br />Signature: ���i Tiue: Safety Operations <br />Leader <br />a.m, .e nrorn2 1 1561, 3 501 <br />