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COUNTY OF SAN JOAQUIN RECEIVED <br /> Environmental Health Department DEC 2 9 2017 <br /> 1868 E Hazelton Avenue <br /> Stockton, (209)46 -3420 ENWRONNIENTAL HEALTH <br /> 5205 <br /> Telephone(209)468-3420 <br /> FAX(209)466-3433 PERMIPSERVICES <br /> Webslte: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 `I <br /> Name: <br /> Business Owner(s) <br /> Name: Telephone: <br /> Business 114og A&4at- 4v2r / nn <br /> Address: 1 i. -- - t c� — C A G 1 53U 4 _ <br /> Mailing Address(if different from r� <br /> above): <br /> Nature of <br /> Business: T'yFire District: <br /> t�t`. `oar I'narn�enanc�- <br /> Q1, 1)ifYas ZINo 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 /> Q2. l 'es 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 ancy, one time In the year? <br /> If'Yes,"how long have you handled these materials at your business? 1'nS ax v� <br /> 6� Jr�b�.a ,�bnrt�1 <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 /> ❑B. This business is a health care facility(doctor,dentist, veterinary,etc.)and uses onIv medical <br /> gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. ❑Yes �No Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. ❑Yes ❑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. 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 o gguthorize42�en`: <br /> X 11{ 1�,, tU Date: <br /> nt Nine�f— <br /> X � Pri� " d Tt Tttle:_ c 0.10 C�,C Lc"t<i <br /> Signature <br /> F/ApplkationsFonneBHendoute/PlenningAppllca6oneBuslneas License(Revised 02-24.16) <br /> Page 4 of 6 <br />