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San Joaquin County DIRECTOR <br /> sq?��"g� Environmental Health Department Donna Heran,REHS <br /> ...... Ervviro PROGRAM COORDINATORS <br /> 1868 E Hazelton Avenue Robert MoCiallon.REHS <br /> Jeff Carrj�esc�,K�!�� <br /> Stockton, California 95205 I(Fse—y5oiey,REHS <br /> • Linda Turkatte,REHS <br /> Website: WWWAgov.orglefid Rodney Estrada,REHS <br /> 1F.0 Phone: (209) 468-3420 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 /> 3z7— <br /> , Telephone: 5Z <br /> We 4 <br /> Business Name: V7- t <br /> Business Site Address.- <br /> Mailing Address(if different from abov Telephone: <br /> Business Owner(s) Name: <br /> .Business owner Address: Fire District <br /> Nature of Business: <br /> at any one time in the <br /> handle a hazardous mate(tal In any quo4y <br /> ❑Yes XNo Does your business h,,n of hazardous material on page 2 of this form- <br /> year? See the definitio YesNo Dsed or Store a hazardous waste b_M quantlN?(used oil, <br /> oes your business ntifreeze,waste solvent, <br /> treat, <br /> uat etc.) of this form and return to the address above. <br /> If your answer is-No'to both questiOns,n Qj'please pont,sign,and date the bottom <br /> Does your business handle a hazardous material, or a mixture containr i200 cubic feet at <br /> ng a hazardous <br /> Q2. o Yes tj No material,In a quantity equal to or greater than 55 gallons,500 pounds,o <br /> any one time in the year? <br /> If"Yea",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 /> o <br /> product packaged for direct distribution to and use by the general public. <br /> This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> ❑ <br /> B. agricultural or horticultural commodity. Hazardous Material? See definition on page 2. <br /> 03. o yes ci No Does your business handle an Acutely <br /> Q4. o Yes 0 NO is your business within 1,000 feet of the outer boundary of a school?(Grades K-12) <br /> -id my requirements under chapter 6.95 of the California Health and <br /> ad the information on this form and understat responsibility to notify the <br /> I have read d that If I Own a facility or property that used by tenants,it Is my re <br /> Safety Gode(HSC). I understarl, issuance of a Gerlificate of occupancy or beginning Of operations. <br /> 1 <br /> f the requirements which must be met prior to and accurate to the best of <br /> tenants 01 n provided on this disclosure survey Is true <br /> declare under the penalty of perjury that the information <br /> my knowledge. <br /> Owner or Authorized Agent Date: <br /> �ozprint Name: (120 <br /> "e -rite: 0 <br /> Signat'le* <br />