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San Joaquin County <br /> oPqulN' c DIRECTOR <br /> ),� - OG Environmental Health Department Donna Heran,REHS <br /> 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> N: Stockton, California 95205 Robed McClellan,REHS <br /> Jeff Canuesco,REHS,RDI <br /> •c:.,�_ .p Kasey Foley,REHS <br /> Rodney Estrada,REHS <br /> 4C!'Fi Website: www.sjgov.org/ehd Linda Turkatte,REHS <br /> Phone: 209 468-3420 <br /> ( ) Adrienne Ellsaesser,REHS <br /> Fax: (209)468-3433 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County. <br /> V. <br /> Business Name:Y'�/ /� r/��I�� S�o/Y�-`� Telepho e: <br /> Business Site Address: lZ O Z 3 E32�}nr� Lc%C1C2 CIA <br /> Mailing Address(if different from above): �tZh�vtJU /'^ <br /> Business Owner(s)Name: Cr/z/2.� f Z*r-muni �yU(,/STelephhone: <br /> n <br /> Business Owner Address: 7 s 46- <br /> Nature of Business: y Fire District: <br /> Q1. ❑Yes &1vO 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 /> o Yes ®'No Does your business generate,treat, or store a hazardous waste in any quant bP(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. o Yes o 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? <br /> If"Yes",check any of the following conditions that apply to your business: <br /> o 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. o Yes o No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. o Yes o No 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). 1 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 Autho' d Agent <br /> Print Name: Date: <br /> Title: <br /> Signature: <br />