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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone(209)468-3420 Fax (209)464-0138 www.sjcehd.com HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and/or address in San Joaquin County. [/ Business Name: N 06)A1 V 121 I�M qA7 `t,41' Telephon f2n 9 Pq 4 ' 19 Business Site Address: 2 lr . L-¢ , , Meiling Address(if different from above): -�- Business Owner(s)Name: h ne: Business Owner Address: 124 J Nature of Business: Fire District: Q1. /yes n No Does your business handle a hazardous material in anyguantttv at any one time in the year? See the definition of hazardous material on page 2 of this form. /es a No Does your business generate, treat, or store a hazardous waste in any auent (used oil, used antifreeze,waste solvent,etc.) H your answer is"No"to both questions In Gil,please print,sign,and date the bottom of this form and return to the address above. Q2. Yes /No Does your business handle a hazardous material, or a mixture containing a hazardous material, in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time in the year? If"Yes',how long have you handled these materials at your business? If"Yes",check any of the following conditions that apply to your business: o A. The hazardous materials handled by this business are contained solely in a consumer product packaged for direct distribution to and use by the general public. ❑B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an agricultural or horticultural commodity. Q3. /Yes o No Does your business handle an Acutely Hazardous Material? See definition on page 2. 04. a Yes /No Is your business within 1,000 feet of the outer boundary of a school?(Grades K-12) I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and 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 tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. 1 declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. If you answered`Yes"to Question 2, please go online to cers.oalema.ca.cov to submit your hazardous materials information. Owner or Authorized Agent:A^ /� Print Name,I 'th`c n 1 1 t"1 U T-A )Af (� Data: Signature:_�� Title: c)\Q h EHD 19-02 1 HMSP SURVEY Revised 8/25116