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JUN/11/2014/WED 09:32 AM CDV111`11TY DEdELOP01 <br />MAY/07/2014AED 02,53 PIA �..-..Ml)NITY DEVELfOPh+MEN <br />JUN 11 Z014 <br />FAX No. 1209937"�3 � ��% <br />FAX No. 120999J.,a93 r IJ <br />1/VmPPRio glg0,&, <br />,ku P400 -C-15;(,-70 <br />San Joaquin County <br />Environmental Healfh Departi�e.nt <br />1$6$ E FlazrYlton AvQnue <br />Stockton, California 95205 <br />Websife: www,sigov.org/elid <br />Phone: (209) 468-3424 <br />�'ax:' (zp9}"468-343 <br />DIRECTOR <br />Lonna Haran. REi,IS <br />PROGRAM COORDINATORS <br />Robert MaCfelion, R HS <br />Jeff Carruesco, PH,% Rol <br />Kaley Foley, RtHS <br />Linda Turkana, RLH$ <br />Rodney Estrada, REH$ <br />Adrienne Ellsaosser, REH5 <br />t�E�,TAL HEALT <br />HAZARDOUS MATERIALS DISCLOSUR12 SURVEY <br />ENVIRC7N, Q separotia survey f❑rm is required for each business name andfor address in Ban Joaqulrt County. <br />OEPARTMENI <br />Business Narne: '� t�41, <br />... .... r �,. eephone:'ZZ <br />Business Site Addrass: TAki E. 4* �� <br />Maiiin Addreif diffiren from above):T <br />ss <br />Business Owners) Name: Telephone:"wd� <br />6uelne3s Owner Address:IM- A AjW4zA;. --%1 1319I08K _1,4 q ; <br />Nature of eusinoss: Firs District: <br />a No Ooea your business handle a hazardous material fL2ay quantity at any one time in the <br />year? S6e the dattnitlen of hazardous material on page 2 of this form. <br />j(LYes a No Does your busfngss generate, treat, or store a hazardous waste (used oil, <br />_....._. _._ _ .. ........ used antifreeza, waste salVant, eto.)-- : - - - -- - - - - — -- - - - - ,_ <br />if your answer is "No" to both quo -Wong In Qi, ploato print, elfin, and date the boftorn of this form and return to the address above. <br />Q2. )Wes 4 No Does your business handle a hazardous maforIA or a mixture.C.ontaining_a hazardous <br />material, In a quantity equal to or greater than 55 gallons, loo pounds, or zoo cubio lout at <br />any one time in the year? <br />If "Yes", hoVv long have you handled these materials at your <br />If "YeV, ehack any of the following conditions that apply to your business: <br />❑ A, The hazardous tmaterlals handled py this bu9lness am c❑ntainod solely in a consumer <br />product pact aged far direct dlstributlon to and use by the general public. <br />❑ B. This business operate 'a brm for purposes of cultivating the aoil, raising or harvesting an <br />agricultural or hortIoUffuigl commodity. <br />03. d Yes Vo Does your business handle an Acutaly Hn,�nrd4ua II See definition on page 2 <br />Q4. Q Yes Y'Vo . Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12) <br />hnve read the information on this fort and understand my requirements under Chapter 5,95 of the California Health and <br />Safety Code (NSC). I understand that if i own a facility or property that is used by tonanta, It Js my resp❑ns6lify to notify the <br />tenants of the requirements which must be met prior to lazuance of a Certificate of Occupancy or beginning of operations. i <br />declare under the penalty of perjury that the information provided an tills disclosuro survey Is true and accurata to the best of <br />my knowledge. <br />Owner or Authorized Agent: <br />Print Nemo; ~1� oatu: ,1 rfl1 <br />Signature: Title: a <br />'i <br />"wN�d 15la7Ji2 <br />