Laserfiche WebLink
COUNTY OF SAN JOAQUIN RECEIVED <br /> Environmental Health Department DEC 2 9 2017 <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 ENVIRONMENTAL HEALTH <br /> Telephone(209)468-3420 <br /> FAX(209)468-3433 PERMIT/SERVICES <br /> Website:www.sjgov.org/ehd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business <br /> name and/or address in San Joaquin County Is required. <br /> Business ---F' <br /> Name: <br /> Business Owner(a) <br /> Name: Telephone: <br /> n(o) l <br /> Business 9 F A4-9-14 4Ve nn S3a0�'RS/3 <br /> Address: ei�_,vv --so � t , 1 �.. (� —� ` r C A t 0 L! <br /> U <br /> Mailing Address(if different from <br /> above): �Q�(�x 13a &n PA t q/oL13 <br /> Nature of <br /> Business: `Tf.kLLk E, noir` 11matrjeAgAc�- Fire District: <br /> 01, y es ONo Does your business handle a hazardous material In any quantity at any one time In the year? See the <br /> ` definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> 02. I 'as ONo Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at cancy one time in the year? <br /> If"Yes,"how long have you handled these materials at your business? 1't a e — IV�,4 a4 )I\�3 <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> OA. The hazardous materials handled by this business is contained solely In a consumer product, <br /> packaged for direct distribution to,and use by, the general public. <br /> OB. This business Is a health care facility(doctor,dentist, veterinary,etc.)and uses only medical <br /> gases. <br /> OC. This business operates a farm for purposes of cultivating the soil,raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. Dyes tr1No Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> / ` form. <br /> 04. Dyes ONo 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. I understand that if I own a facility or property that is used by tenants,that 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. <br /> I declare under the penalty of perjury that the Information provided on this disclosure survey Is true and accurate to the <br /> best of my knowledge. <br /> Owner oyguthodzeq.Aoen{: <br /> x Date: la laJ h1 <br /> Print N e <br /> X TMe:_ Sr ak N-C—CC n sn'4 <br /> Signature <br /> F/AppllcationsFornaBHendoutslPlanningApplicatlone/Business License(Revised 02-24-16) <br /> Page 4 of 6 <br />