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RECEIVED <br /> JAN 062016 <br /> �o�ufN <br /> San Joaquin County ENVIRONMENTAL <br /> ENVIRONMENTALH <br /> S <br /> TN <br /> t DIREpp��AMITSERVICESEnvironmental Health Departmen /1868 <br /> E Hazelton Avenue <br /> �• 4 Stockton, California 95205 Robert COORDINATORS <br /> '. <br /> D11 .,.. V. Clellon,RENS <br /> !,!URN' Jeff Carruesco,REHS,RDI <br /> Website: www.sjgov.org/ehd Kasey Foley.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 DICKS SPORTING GOODS #1176 Telephone 209-992-5745 <br /> Business Site Address: 5354 PACIFIC AVENUE, STOCKTON, CA 95207 <br /> Mailing Address(if different from above): 5151 SAN FELIPE STREET, STE 1000, HOUSTON, TX 77056 <br /> Business Owner(s)Name DICKS SPORTING GOODS, INC Telephone 724-273-3400 <br /> Business Owner Address: 345 COURT STREET, CORAOPOLIS, PA 15108 <br /> Nature of Business. SPORTING GOODS RETAILER Fire District: STOCKTON FIRE STATION 4 <br /> Q1. X Yes 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 /> X Yes 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 Q1,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2 X Yes ❑ 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? 7 MONTHS <br /> If"Yes", check any of the following conditions that apply to your business: <br /> XX 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. ❑Yes 'X No Does your business handle an Acutely Hazardous Material? See definition on page 2 <br /> Q4. X Yes 2 No Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12) <br /> �,wie 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 <br /> of the under the penatyts which of perjury thatbe met the nforrmlor atioo issuanceprovided on ath sedilscclosu e ssurveoccupancy <br /> y is truer and beginning <br /> rate to theoperations. <br /> best of r <br /> declare <br /> my knowledge. <br /> Owner or Authorized Agent. / <br /> Date: /7 �3a le 21 � <br /> Print Name <br /> Title <br /> Signature Ak4--(2� [4--,; - -Vle—r-16-1 rcl� <br />