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San Joaquin County <br /> DIRECTOR <br /> Environmental Health Department Donna Heran,REHS <br /> _fir a '..y <br /> y 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> Stockton, California 95205 Robert McClellan,REHS <br /> Jeff Carruesco,REHS,RDI <br /> o•Fl k(�1'r' �P • Kasey Foley,REHS <br /> Website: www.sjgov.org/ehd Linda Tufkalte,REHS <br /> Phone: (209)468-3420 Rodney Estrada,REHS <br /> Fax: (209)468-3433 Adrienne Ellsaesser,REHS <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form Is required for each business name and/or address in San Joaquin County. <br /> Business Name:�1\MY\1\CK CCX\WCC CO-.\Y-Xt • Telephone: <br /> Business Site Address: b t A <br /> Mailing Address(if different from above):Uwo, 2C�eV.1inm SAf�- Im. ocw( n(` , CA GkA(D'L l <br /> Business Owner(s)Name:EW 00 000!aTelephone: <br /> Business Owner Address: <br /> Nature of Business: QOc�Y��CUmm Fire District: <br /> Q1. XYes ❑No Does your business handle a hazardous material in any quantity at any one time In the <br /> year? See the definition of hazardous material on page 2 of this form. <br /> 1pNes ❑No Does your business generate,treat,or store a hazardous waste in any quantity?(used oil, <br /> used antifreeze,waste solvent,etc.) <br /> If your answer is"No"to both questions In Q1,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2. WYes u No 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 materials at your business? M\Q(A <br /> If"Yes",check any of the following conditions that apply to your business: <br /> ❑A. 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 /> ❑B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. a Yes 1!o Does your business handle an Acutely Hazardous Material? Sea definition on page 2. <br /> Q4. u Yes /fJo 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(HSC). I understand that if I own a facility or property that is used by tenants, 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. I <br /> declare under the penally of perjury that the information provided on this disclosure survey is true and accurate to the best of <br /> my knowledge. <br /> Owner or Authorized Agent: P,�S <br /> Print Name:D.IN\" V Date: QAJ()A�`A <br /> FOR SHIMMICK CONST CO..INta <br /> Signature: Title: u <br /> 1 <br /> arre.e tw,nx <br />