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COUNTY OF SAN JOAQUIN Environmental Health Department 1868 E Hazelton Avenue Stockton, California 95205 Telephone (209)468-3420 FAX (209)468-3433 Website www.sjgov.org/ehd HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the information on the reverse side before completing this survey form. A separate survey for each business name and/or address in San Joaquin County is required. Business Name: �/l Business Owner(s) n Name: �,I� j� f�„/2 _ Telephone: )t? 2 — Business �t Q Address: _L...7 2_Z- Mailing Address (if different from above): Nature of Business Fire District: Qt. �IYes ❑No Does your business handle a hazardous material in any quantity at any one time in the year?- See the /� definition of hazardous material on the back of this form. If your answer is No," go to Question 4. 02. XrYes ❑No Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity equal to or greater than 55 gallons, 500 pounds,or 200cubic feet at any one time in the year? If"Yes." how long have you handled these materials at your business?__-- e2-- If If"Yes,"check any of the following conditions that applies to your business. A. The hazardous materials handled by this business is contained solely in a consumer product, packaged for direct distribution to, and use by, the general public. ❑B. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or horticultural commodity. Q3. ❑Yes o Does your business handle an acutely hazardous material? See definition on reverse side of this `\ form. 04. QYes(i�ls your business within 1,000 feet of the outer boundary of a school (grades K-12)? I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety Code. I understand that if 1 own a facility or property that is used by tenants, that it is my responsibility to notify the tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owner o uthorized Ager+ / 1 X_ �� —1_Ta'�' Date: _ Print a qty X Title: //..r.�,e -+-/ ignature F Applic tonsPonns&HandouL-/PlanningApplir bons/Business License(Revised 02-2415) Page 4 of 6