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o N San Joaquin County <br /> DIRECT-OR <br /> Environmental <br /> Environmental Health Department Donna Heran,REHS <br /> 1868 E Hazelton Avenue <br /> N: a PROGRAM COORDINATORS <br /> • Stockton, California 95205 Robert McClellon,REHS <br /> Jeff Caruescc,REHS,RDI <br /> .... . Kasey Foley,REHS <br /> Website: www.sjgov.org/ehd Linda Turkatte,REHS <br /> Phone: (209)468-3420 Rodney Estrada,REHS <br /> Fax: (209)468-3433 Addenne Eleaesser,REHS <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate surveyform is required for each business name and/or address in San Joaquin County. <br /> Business Name: Telephone: <br /> Business Site Address: `77� ►V • ww OL 5&f(4l+nzn 2D <br /> Mailing Address(if different from above): )L34 (Zz m 1 N(nvN w." I �,o Cr <br /> Business Owner(s)Name: 744H t U-i Oet+ Q A-(s"A,^7 Telephone: �Jq-S 15—a q7 j <br /> Business Owner Address: 16`1 ( Rq�MI n1� nN �JNI L Jr�l (�1 '-y)LjZ <br /> Nature of Business: [,A( . AfMCM,.1n• ' kR-AI .rhr4- Fire District: <br /> Q1. o Yes vINo 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 mrNo Does your business generate,treat, or store a hazardous waste in any quantity? (used oil, <br /> used antifreeze,waste solvent,etc.) <br /> Ifyouranswer Is"No"to both questions in O],.please print,sign,and date the bottom of this form and return to the address above. <br /> Q2. ❑Yes ❑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 matedals at your business? <br /> If"Yes', check any of the following conditions that apply to your business: <br /> D 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 /> ❑B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes ❑No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. o 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 Califomia 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. 1 <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: <br /> Print Name: �1. iWAltf1 G Date: 03/ly/IL <br /> Signature: 1 ' / \ Title: o`^'NJVO­ <br />