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San Joaquin County <br /> ❑p4!!!(y,•PDIRECTOR <br /> ?•' ''^+? Environmental Health Department Donna Horan,REHS <br /> 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> Stockton, California 95205 Robed McClallon,REHS <br /> Jeff Corruesco,REHS,RDI <br /> • r'o Kasey Foley,REHS <br /> q<)HoaN� Website: www,sjgov.org/ehd Linda Turketle,REHS <br /> Phone: (206)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 /> Buslness Name: Louis Rivera Trucking, Inc. Telephone: 209-887-2725 <br /> Business Site Address: 2715 N. Snyder Lane, Stockton. CA 95215 <br /> MailingAddress(if different from above): PO Box 1121, Linden, CA 95236 <br /> Business Owners)Name: Louls Rivera Telephone: 209.887-2725 <br /> Business Owner Address: same as above <br /> Nature of Business: Truck Maintenance/Repair Fire District: Waterloo/Morsda <br /> Q1. ❑Yes to Does your business handle a hazardous material In any cuantity at any one time In the <br /> year? See the definition of hazardous material on page 2 of this form. <br /> q"fes o No Does your business generate,treat,or store a hazardous waste In any cuantity?(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 /> 02. ❑Yes ao 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'Yee,how long have you handled these materials at your business? <br /> 11"Yee. check any of the following conditions that apply to your business: <br /> ❑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 soil,raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes o Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes 140 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 8.95 of the California Health and <br /> Safely 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 /> Fel',c.Wd, <br /> Print Name: 6euls Rivera Date: <br /> Signature, / r`O Title: DlA1NtC <br /> 1 <br /> a,511d uwmz <br />