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� V <br /> oP0.4?[N San Joaquin County <br /> Environmental Health De„artment DIRECTOR <br /> Donna Haran,REHS <br /> �+#4.- r <br /> t 1868 E Hazelton Avenue <br /> r Stockton, California 95205 PROGRAM COORDINATORS <br /> •::':--- . - - -"; •' Robert McClellon,REHS <br /> Jeff Cenuesco,REHS,RDI <br /> OR�� Kasey Foley,REHS <br /> Website; www.sjgov.org/ehd Linda Turkatle,REHS <br /> Phone: (209)468-3420 Rodney Estrada, REHS <br /> Fax: (209)468-3433 Adrienne Ellsaasser,REHS <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate sum form is required for each b siness name and/or address in San Joaquin County. <br /> g 5 #W7Yv6l T7 el )' Y <br /> BusinessteName: ) _ d Teephone: ZOdJ . /—'7O5C., <br /> Business <br /> Site <br /> Address:_Z G a70LY/l r� �m• S /�y� j¢ d� 7GrJ S <br /> Mailing Address(if different from above): <br /> Business Owner(s) Name: ` e: ' D Telephon ,. �(J <br /> Business Owner Address: j2d2� UNDD 1�1/ GN <br /> Nature of Business: Fire District: <br /> Q1. W% es 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 /> Wfe s o 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 41,please print,sign,'and date the bottom of this form and return to the address above. <br /> Q2. w1f'es 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? 2 /MOW <br /> If'Yes",check any of the following conditions that apply to your business: <br /> ¢f.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 /> o B. This business operates a farm for purposes of cultivating the soli, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. o Yes ol�No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑YesM\ <br /> No Is your business within 1,000 feet of the outer boundary of a school?(Grades KA2) <br /> 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 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: 1 /r� <br /> Print Name: © Date: 1 o— I q <br /> Signature Title: <br />