Laserfiche WebLink
COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> Telephone (209) 468-3420 <br /> FAX (209)468-3433 <br /> Website: www,sjgov.org/ehd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business <br /> name and/or address in San Joaquin County is required. <br /> Business <br /> Name: <br /> Business Owner(s) <br /> Name: , Telephone: 'Off I <br /> Business A <br /> Address: Z„ � F_fti_ h+�C +f` 4l 37!v <br /> Mailing Address (if different from <br /> above): <br /> Nature of — - — — - --- -- - <br /> Business: &C � 1 _ �t.� Fire District: /Q <br /> Q1. dYes ❑No Does your business handle_a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> 02. I(Yes ❑No Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at any one time in the year? <br /> If"Yes,"how long have you handled these materials at your business? <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> OA. The hazardous materials handled by this business is contained solely in a consumer product, <br /> packaged for direct distribution to, and use by, the general public. <br /> ❑B. This business is a health care facility(doctor, dentist, veterinary, etc.) and uses only medical <br /> gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> // agricultural or horticultural commodity. <br /> Q3. ❑Yes ®No Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> rr form. <br /> Q4. ❑Yes ®No is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code. I understand that if I own a facility or property that is used by tenants, that 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. <br /> I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge. <br /> Owner o Authorized Agent. <br /> X Z d Z. Date: fD" 10-1 S <br /> rint Name <br /> X Title: W V7-4Fi <br /> Si ure <br /> F/ApplicationsFomis&Handouts/PlanningApplications/Business License(Revised 02-24-15) <br /> Page 4 of 6 <br />