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COUNTY OF SAN JOAQUIN <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Telephone (209) 468-3420 <br />FAX (209) 468-3433 <br />Website: www.sjgov.org/ehd <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />Please read the information on the reverse side before completing this survey form <br />name and/or address in San Joaquin County is required. <br />Business <br />Name: i3 L J It Y Y- `>v-4-73 1" <br />Business Owner(s) <br />Name: <br />Business <br />Address: <br />2230 <br />If <br />12 J <br />4C,� <br />RECEMD <br />JUN 06 2019 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />A separate survey for each business <br />f / <br />Telephone: <br />Mailing Address (if different from <br />above): <br />Nature of <br />Business: , I,�D "r <br />U+ F12-01— <br />/1", 1 Signature Ld f - <br />Fire District: Crlo-(5 zGLe—, <br />Q1. Pes []No Does your business handle a hazardous material in any quantity at anyone time in the year? Seethe <br />definition of hazardous material on the back of this form. If your answer is No," go to Question 4. <br />Q2. JOes ❑No Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br />quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at 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 applies to your business. <br />❑A. The hazardous materials handled by this business is contained solely in a consumer product, <br />packaged for direct distribution to, and use by, the general public. <br />❑B. This business is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical <br />gases. <br />❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br />agricultural or horticultural commodity. <br />Q3. ❑Yes/11No Does your business handle an acutely hazardous material? See definition on reverse side of this <br />form. <br />Q4. ❑Yes 9No 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. I understand that if I own a facility or property that is used by tenants, that 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 />I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br />best of my knowledge. <br />Owner or uthorized Agent: <br />X �e s -e- P. q &An 114 Date: 7cw? <br />rin ame w�z7o <br />X 4ATitle: <br />Signature <br />F/ApplicationsForms&Handouts/PlanningApplications/Business License (Revised 11-7-2018) Page 5 of 6 <br />