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Op4�lN COUNTY OF SAN J�. .QUIN Environmental Health Department 1868 E Hazelton Avenue Stockton, Califomia 9520-5 • 4�!FO.R�iIP" Telephone (209) 468-3420 FAX (209) 468-3433 Website: www.sjgov.org/ehd HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the information on the reverse side before completing this survey form. A separate survey for each business name and/or address in San JoaquinCountyis required. Business Name: r,` Business Owner(s)Name: L-t i A'LTelephone: Business Address: Mailing-Address (if different from above): NatureofBusiness: CSO/-1 V� /�� c50OQ� Fire District: Q1. Rfes ❑No Does your business handle a hazardous material in any quantity at any one time in the year? See the definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. Q2. QYes []No Does your business handle a hazardous material,or a mixture containing a hazardous-material in a quantity equal to or greater than 55 gallons, 500 pounds, or 20Dcubic feet at any one time in the year? If"Yes," how long have you handled these materials at your business? '04C' VR—'5 If"Yes,"check any of the following conditions that applies to your business. The hazardous materials handled by this business is contained solely in a consumer product, packaged for direct distribution to,and use by, the general public. ❑B. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or horticultural commodity. Q3. ❑Yes 131f ooDoes your business handle an acutely hazardous material? See definition on reverse side of this-form. � Q4. ❑Yes [91151s your business within 1,000 feet of the outer boundary of a school (grades K-12)? 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and 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 tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owner or Authorized Agent: X—�� "A" Date: Pre X /.! — Title: owiry k Signature FADEVSMPlanning Application Foms\Site Approval.(Revised 02-03-10) Page 7 of 10