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San Joaquin County <br /> DIRECTOR <br /> � y <br /> Environmental Health Department DonnannoHoran,REHS <br /> 1868 E Hazelton Avenue PROGRAM COORVINATORS <br /> Stockton California 95205 Robert McCtouon,REHS <br /> '°" .• ° Jag Carruesco,REHS,RDI <br /> riwLidTurksoy atte,REHS <br /> ,REHS <br /> Website: vn .sjgov,org/end ( <br /> Phone: (209)468-3420 Rodney Estrada,RENS <br /> Fax: (209)468.3433 Adrienne Ellsaessay 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 /> wzgotQs/t(Lc -1WW',itmedl. <br /> Business Name:. . _j;j,[} vy - _Telephone: 2lF'7 yJ'�-�y 2 <br /> Business Site Address: 11 e diA4p A r,t"e4 <br /> Melling Address(if different from above):._L'nodk 19[L_Lr�rl(Co �t �/�- �,,Utz , <br /> Business Owner(s)Name:Tb of eof e PdzQ, T//_`` e"�lephone: ?G9 7"L1V(r j�J <br /> Business Owner Address: .2151GOrk'�/it ;! �r A)ej)J4-.14IIG 324W46 A4,»e <br /> Nature of Business:. .5 r/tA'r'ol- _ Fire District, <br /> Q1. ,dyes o 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 /> ❑Yes dAo Does your business genorate,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 Qt,please print,sign,and data the bottom of this form and return to the address above, <br /> Q2, Ayes o 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? 14"a--Z-1115 <br /> �i yS44 �+t.44g <br /> It Yss',check any of the following conditions that apply to your business <br /> o A. The hazardous materials handled by this business are contained solely In a consumer <br /> product packaged for direct distribution toand use by the general public. <br /> o B. This business operates a farm for purposes of cultivating the soil,raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. n Yes No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. u Yes prNO 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 Cal'dornla 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 penalty 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: <br /> Print Name: QezzAlli 1..... '911 Date: I'tno 12, <br /> Signature-"4/jW 7 ) TI0o: I (eJIOCCI✓1 <br />