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r1t:UtIVtU <br /> RECEVED 1.00 APR 14 2014 , <br /> San Joaquin County EWHEINMENTAL HEALTH <br /> APR L4 ZQtronrnental Health Department oonMMATMENT <br /> r 2` 68 E Hazelton Avenue P <br /> EW Robert PROGRAM COORDINATORS <br /> Robert McClellon,REHS <br /> PERMIPSERVICEStockton, California 95205 <br /> Jeff Canuesco,REHS,RDI <br /> '•2i Kasey Foley,REHS <br /> Website: wwwsjgov.org/ehd Linda Tu kaae,REHS <br /> 209 468-3420 Rodney Estrada,REHS <br /> Phone: <br /> ( ) Adrienne Ellsaesser,REHS <br /> Fax: (209)468-3433 <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 N / <br /> ame: ,oeZ l-wSfJ•"t Telephone: a0�7- 6�y - �C3U3 <br /> Business Site Address: !1 <br /> Mailing Address(if different from <br /> /abov1e): 1�9g�-a e �� [�1 c oC 'oa <br /> Business Owner(s)Name: f=are 111J / !0 Pq L Telephone: ;-09-G/`le -e1703 <br /> Business Owner Address: Tor A e ZI Qr <br /> �t <br /> Nature of Business: _,mr- fle. 0�-Qomac2S•,/ ire DistricC Of TZ Krl <br /> Qt. dynees ❑ 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 /> VY/es 2 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 01,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2. dyes ❑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? 1 1b. � OA L 5 <br /> � If"Yes", check any of the following conditions that apply to your business: <br /> XThe 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 /> 03. ❑Yes 140 Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes 4.4.0 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 f Authorized Agent: / <br /> Print Name: G�e `V�l"-U l/l& (�Jr j�Z Date: <br /> t <br /> Signature: - Title: 62K-ti -e <br /> 1 <br /> R.I I MII12 <br />