Laserfiche WebLink
San Joaquin County <br /> o0.4k!I DIRECTOR <br /> ? � �^? Environmental Health Department Donna Heran,REHS <br /> W.... 1868 E Hazelton Avenue <br /> �--�� - � �.� PROGRAM COORDINATORS <br /> Stockton, California 95205 Robed McClellon,REHS <br /> Jeff Canuesco,REHS,RDI <br /> . - .. „r�P Kasay Foley,REHS <br /> H0 Website: www,sjgov.orglehd Linda Turkatle,REHS <br /> Phone: (209)469-3420 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: Louis Rivera Trucking, Inc. Telephone: 209.887-2725 <br /> Business Site Address: 2715 N. Snyder Lane, Stockton,CA 95215 <br /> Mailing Address(if different from above): PO Box 1121, Linden, CA 95236 <br /> Business Owner(s)Name: Louis Rivera Telephone: 209-887-2725 <br /> Business Owner Address: same as above <br /> Nature of Business: Truck Maintenance/Repair Fire District: Waterloo/Morada <br /> Q1. ❑Yes WC Does your bustness handle a hazardous materiel 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 to 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 bottmn of this farm and return to the address above. <br /> 02. ❑Yes o 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? <br /> If'Yes',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 /> ❑B. This business operates a form for purposes of cultivating the sell, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes 40 Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes 1,040 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 /> 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 /> F{//fcn�rri ' <br /> Print Name: ms Rivera n Date: Z'I C-/ 14 <br /> Signature:,� � R cC/Q - Title: QLAIi,3tC <br /> 1 <br /> ReXsed 1007112 <br />