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. y <br /> San Joaquin County <br /> ",9, .1. DIRECTOR <br /> Environmental Health Department Donna Heran,REHS <br /> ' J21 <br /> 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> J Robert Mccleilon,REHS <br /> ;.J Stockton, California 95205 <br /> Jeff Carruasco,RENIS,RDI <br /> Kasey Foley.REHS <br /> -� F'gLinda Turkalle,REHS <br /> Website: www.sjgov.org/ehd <br /> Phone: (209)468-3420 Rodney Esirada,RCHS <br /> Fax: (209)468-3433 Adrienne Elisaesser,REH5 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey for�rm(m iisst required for each business name and/or address in San"Joaquin County <br /> . �17 <br /> Business Name: J ) I ` (1 ) -C. TTelephone: 6 J- ,33 1 . / / f <br /> Business Site Address 40��1) 1�.��n� I ICY alo A q 4'3 O r <br /> Mailing Address(if different from above): !1 <br /> Business Owner(s)Name: Apir" Zhonc. Telephone: �t'7µ,, ' 7 q vov <br /> �/ <br /> Business Owner Address' (7r L L?n V� ^�l Fl�r AOA !'ly�L A-I ! 3 D I <br /> Nature of Business: S�ola.r � QG Lc Ue � Fire District: (�al� AH,0 <br /> Q1. r Yes A 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 01,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2. c Yes WIND 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 yeaO <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 /> n B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. r Yes n No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. r Yes `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). 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: L <br /> , pr,I Zh�n°L 2/ /3 /-)-0)3 <br /> Print Name: ' p ((�� Date: 7� <br /> Signature: mom— Title: C ED <br /> 1 <br />