Laserfiche WebLink
San Joaquin County <br /> DIRECTOR <br /> p r Environmental Health Department Donna Heran,REHS <br /> 4 X11 G�+ 1868 E Hazelton Avenue <br /> PROGRAM COORDINATORS <br /> Stockton, California 95205 Robert MCClellon,REHS <br /> Jeff Carruesco,REHS,RDI <br /> Kasey Foley,REHS <br /> 0 ` Website: www.sjgov.org/ehd Linda Turkatte,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: 1�i,t'.iG c �)rZ� %� JUi.r iv;c. Telephone: 9[6.1 �L12 c1 U)c, <br /> Business Site Address: <br /> Mailing Address(if different from above): <br /> Business Owner(s)Name: t—o s� �?o Lr= /t%�J NrrC�r 'l li• i Telephone. J01-1 '� ri �i k i c <br /> G-G ..v J� �r7 1 ' <br /> Business Owner Address: l(4.c t nJ f •�i C.i, �° r� - L o r� � C iy <br /> Nature of Business:_ Ery ;fit;.' Fire District: ^�..h?e� C. �(✓iU l;_,'c r.)f <br /> Q1. Yes ❑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 /> Yes ❑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. Yes Li 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? i ; <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 farm for purposes of cultivating the soil, raising or Harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. KYes ❑No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes �o 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. <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 /> Print Name: Date: i�j�l <br /> Signature: �: .._.��-_�____ ,_ Title: GC,, 7i7 1L.. <br /> Revised 11107/12 <br />