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San Joaquin County <br /> 1111 <br /> - -` Environmental Health Department D1 DonnaHeran.REHS <br /> 1868 E Hazelton Avenue <br /> PROGRAM COORDINATORS <br /> Stockton, California 95205 Robert McClellon,REHS <br /> Jeff Carruesco,REHS.RD1 <br /> ii c p'F��- Kasey Foley.REHS <br /> Website: WWW.Slgov.org/ehd Linda Turkall REHS <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: YAgq. I'ytr //t01 Sell Telephone: <br /> Business Site Address: Pi 719 III TAi2ed-ti 1osr/i <br /> Mailing Address(if different from above): /S/ Ken fV K t1-P FI Ng m 4e y ell 9533 7 <br /> Business Owners)Name. �n�aPr l ,f P('I�r1 91 Telephone: _ 1 :1 410 700 <br /> Business Owner Address: 151 P5e44VtII &I Wan l I., l fs- 7 <br /> Nature of Business: -11i k, kJel LV_he 4Nd je(il r1! Fire District: l <br /> Yes v No Does your business handle a hazardous material in anv Quantity at any one time in the <br /> year? See the definition of hazardous material on page 2 of this form. <br /> Y Yes 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 D1,please print,sign,and date the bottom of this forth 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 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 /> product packaged for direct distribution to and use by the general public. <br /> c B. This business operates a farm for purposes of cultivating the split, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. a Yes 0 No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> 04 m Yes X No Is your business within 1,000 feet of the outer bounds of school)boundary a (Grades K42) <br /> I have read the information on this forth and understand my requirements under Chapter 6.95 of the California Health and <br /> Safely Code (HSC). 1 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 disGosure survey is true and accurate to the best of <br /> my knowledge. <br /> Owner or Authorized Agent: r <br /> Print Name: FYrriE�-H I{ .Com. K R 2t q rV eZ- _Date <br /> Signature Title:l� i .� w, Title: V• 9' <br />