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San Joaquin County <br /> op.,, P_,.,• oDIRECTOR <br /> Environmental Health Depart <br /> ment DonnaHeran,REHS <br /> 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> Stockton, California 95205 RobertCarrue lellon,REHS <br /> :�. Jeff arruesco,RENS,RDI <br /> Kasey Foley,REHS <br /> Website: www.sjgov.org/ehd Linda Turkatte,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: TEG. E&u kP H eMr Telephone: `A09) $56 —y II O <br /> Business Site Address: ZO S O le Liu c St Ptyc I-•J 'rH e-oP CA , '75330 <br /> Mailing Address(if different from above): <br /> Business Owner(s)Name: Telephone: <br /> Business Owner Address: <br /> Nature of Business: D AwelLsHc P 5tX%hCAL` CAPN�ire District: f4 W <br /> Q1. wlYes ❑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 /> es ❑ 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. �s ❑ 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? JAiJ <br /> If"Yes",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 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. o Yes W Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. o Yes 7O 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 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: Date: <br /> Signature: T <br /> 1 <br /> Revised 11/07/12 <br />