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MAY/01/2017/MON 07:07 AM <br />�.y <br />10,.., F - <br />APR 21 2011 <br />„e;o?r's slo <br />FAX No, <br />San Joaquin County <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.slgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />RECOVED <br />NO 01 2017 <br />- NVIRONMENTAL HEALTH <br />DIRECTOR ?TMENT <br />Donna Heran, RENS <br />PROGRAM COORDINATORS <br />Rohart McClellon, REHS <br />Jeff Carruneco, REHS, RDI <br />Kasey FWey, REHS <br />Llnda Turkabe, REHS <br />Rodney Estrada, RENS <br />Adrienne Elisaessar, REHS <br />P( mit <br />,�CenjE(i`�' HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form Is required for each business name and/or address in Ban Joaquin County, <br />168-339 Ancillary Bldg, Imaging Dept. RIF Room Equipment Replacement Prolect <br />Business Name: Kaiser Permanente Stockton Telephone: 209-476-3649 <br />Business site Address: 7373 West Lane, Stockton, CA 95210 <br />Mailing Address (If different from above): <br />Business Ownar(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 />of. yp Yes o No <br />Does your business handle a hazardous material in any ouentity at any one time In the <br />year? See the definition of hazardous material on page 2 of this form. <br />X Yes D No <br />Does your business generate, treat, or atom a hazardous waste In any ouantitv7 (used oil, <br />used antifreeze, waste solvent, etc.) <br />if your answer is "No" to both questions <br />in Q1, please print, sign, and date the bottom of this form and return to the addreea above. <br />02. m Yes o 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 materiels at your buslness0 9 Years <br />If "Yes", check any of the following conditions that apply to your business: <br />o 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 />0 6. <br />This business operates a farm for purposes of cultivating the soli, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. DS Yes o No <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />04. o Yes K 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 (HBC). I understand that If I own a facility or property that is used by tenants, It is my responsibility to ratify the <br />tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning or operations. I <br />declare under the penalty of pelf ury 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. Shemy L. Ramirez <br />04/18/17 <br />Signature: - rine: Prolect Managep <br />R -,W I M1112 <br />