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San Joaquin County DIRECTOR <br /> Environmental Health Department Donna Heran,REHS <br /> f AGPROGRAM COORDINATORS <br /> 1868 E Hazelton Avenue Robert Mcciellon,RENS <br /> >`he.. California 95205 Jeff CarTesco,REHS,Rol <br /> Stockton, <br /> �:. �Kasey Foley,REHS <br /> Linda Turkatte,REHS <br /> Q Website: www•s19ov.org/ehd Rodney Estrada,REHS <br /> <<.F ORS 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 /> r. S Telephone: 2d / 3 Z7– 8 <br /> 17-5` 440 <br /> Business Name: i G 0 L U S r e e r <br /> Business Site Address: <br /> Mailing Address(if different from above): Telephone: <br /> Business owner(s) Name: <br /> Business Owner Address: / Fire District: <br /> Nature of Business: <br /> In any at any one time in the <br /> No Does your business handle hafdouous Mial onlpage 2�f this f°m'- <br /> Q1 ❑Yes year? See the definition of <br /> your business generate,treat,or store a hazardous waste in any quantity? (used oil, <br /> No Does y etc. <br /> ❑Yes used antifreeze,waste solvent, ) <br /> lease print,sign,and date the bottom of this form and return to the address above. <br /> If your answer is"No"to both questions in Q7,P pounds, i 200 cubic feet at <br /> Yes ❑ No Does your business handleequal <br /> t to or greater than 55 gallons,500 Pe containing a hazardous <br /> QZ, ° material,In a quantity q <br /> any one time in the year? i our business? <br /> if'Yes",how long have you handled these materia,s a j your <br /> our business: <br /> If"Yes', check any of the following conditions that apply Y <br /> °A. The hazardous mf�d�ect dns�f�utbionthis <br /> toi and uiness are se by the geneaal public. <br /> ined ly in a consumer <br /> product packaged <br /> °B This business operates afar poses of cultivating the soil,raising or harvesting an <br /> agricultural or horticultural <br /> commodity <br /> I? See ia . <br /> Q3 inYes ❑No Does your business handle an Acutely Hazardous Materof aschool?f i(��des Kp2)2 <br /> Q4. <br /> ❑Yes ❑No Is your business within 1,000 feet of the outer boundary <br /> requirements under Chapter 6.95 of the California Health and <br /> Property that is used by tenants,it is my responsibility to notify the <br /> I have read the information on this form and understand my q or beginning of operations. I <br /> Safety Code (HSC). I understand that if I own a facility or p P hY <br /> that the information provided on this disclosure survey is true and accurate to the best of <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupant <br /> declare under the penalty of perjury <br /> my knowledge. <br /> Owner or Authorized Agent'. A/ IL Date: , <br /> Print Name: Caro <br /> Grvch—� <br /> Signature. <br /> X) Title: O <br />