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San Joaquin County <br /> op4u!N <br /> Environmental Health Department DD nnaOHeran,REHS <br /> z 1868 E Hazelton Avenue <br /> ai PROGRAM COORDINATORS <br /> Stockton, California 95205 Robert McClellon, REHS <br /> Jeff Carmesco,REHS,RDI <br /> q Kasey Foley,REHS <br /> /FORS Website: www.sjgov.org/ehd Linda Turkatte,RENS <br /> Phone: (209) 468-3420 Rodney Estrada,REHS <br /> Fax: (209) 468-3433 Adrienne Ellsaesser, REHS <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County. <br /> Business Name: HD Supply Construction and Industrial White Cap Telephone: 1(714)936-3754 <br /> Business Site Address: 3601 Navone Rd Stockton Ca 95215 <br /> Mailing Address(if different from above): 6250 Brook Hollow Pkwy, Norcross, GA 30071 <br /> Business Owner(s) Name: John Staigman Telephone: 1(770)280-5125 <br /> Business Owner Address: 6250 Brook Hollow Pkwy, Norcross, GA 30071 <br /> Nature of Business: Warehousing Fire District Waterloo Merada <br /> Q1. a Yes ❑ No Does your business handle a hazardous material in anyguantiri at any one time in the <br /> year? See the definition of hazardous material on page 2 of this form. <br /> E Yes a 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 Qt,please print,sign,and date the bottom of this forth and return to the address above. <br /> 02. a Yes a 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 materials at your business? 6 years <br /> If"Yes", check any of the following conditions that apply to your business: <br /> a 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 /> e B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes a No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes ❑ No is your business within 1,000 feet of the outer boundaryof a school?(Grades K-12) <br /> I have read the information on this forth and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code(HSC). I understand that if I awn 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 We and accurate to the best of <br /> my knowledge. <br /> Owner or Authorized Agent: <br /> Print Name: Chris Reitzel Date: 04/28/2016 <br /> Signature: Title: Project Manager <br /> 1 <br /> ReNvetl ilM)Itt <br />