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o 0.gDIN C San Joaquin County DIRECTOR <br /> �,^ 9 Environmental Health Department Donna Hersh,REHS <br /> 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> Stockton, California 95205 Robert McClellon,REHS <br /> Jeff Carruesco,REHS,RDI <br /> Kasey Foley,REHS <br /> crvo�N Website: www.sjgov.org/ehd Linda Turkatte,REHS <br /> Phone: (209)468-3420 Rodney Estrada,REHS <br /> Fax: (209)468-3433 Addenne Ellsaesser,REHS <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for <br /> 11each business name and/or address in San Joaquin County. <br /> Business Name: MOV*4w (K�l.Jol'�lJ� I �V1G. Telephone: V38 �25Sy <br /> Business Site Address: 24iOTS4 'RIQMU fZb Er=CAA.oNe 1 CA , QS32.0 <br /> Mailing Address(if different from above): ds"16 04'S Aftc11� <br /> Business Owner(s) Name: MIKE M0I%VLIL1.- Telephone: 2401. <br /> Business Owner Address: 1bAr4%V ,45 A4fto% C <br /> Nature of Business: Fire District: <br /> Q1. u Yes �No 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 YesNo Does your business generate, treat, or store a hazardous waste in any quantity? (used oil, <br /> �d1 <br /> X used antifreeze, waste solvent, etc.) <br /> If your answer is"No"to both questions in 01,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2. u Yes ANo 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? <br /> If"Yes", check any of the following conditions that apply to your business: <br /> u 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 /> u B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. u Yes >(No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. q Yes MNo Is your business within 1,000 feet of the outer boundary of a school?(Grades K-12) <br /> I have read the inform'a`tion on this form and understand my requirements under Chapter 6.95 of the California 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. I <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 <br /> Agent: <br /> Print Name:_ ��r Date: �jlfi�� <br /> Signature: //l Title: .�7a �/G64r�Y✓ <br /> 1 <br /> ReNsed 11N]tl3 <br />