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COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> '1868.E Hazelton Avenue <br /> Stockton, California-95205 <br /> -Telephone(209)4-G8-3420 <br /> FAX(209)468-3433 <br /> Website:www.sjgov.org/ehd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this-survey form. A separate survey for each business <br /> name and/or address in San Joaquin County is required. <br /> Business <br /> Name: <br /> Business Owner(s) <br /> Name: --_ Telephone: <br /> Business U t <br /> Address: 3 l` <br /> Mailing Address(if different from n X 1� 5 `� AJ <br /> above): � ,�Q W (� <br /> Nature of <br /> Business: ///J� /JnL Jr e lif Fire District: <br /> Q1. ❑YesyNo Does your business handle a hazardous material in any quantity at-any one time in the year?-See the <br /> definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2. ❑Yesbo4o Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons, 500 pounds,or 200cubic feet at 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 applies to your business. <br /> DA. The hazardous materials handfed by this business is contained solely in a consumer product, <br /> packaged for direct distribution to,and use by, the general public. <br /> ❑B. This business is a health care facility(doctor,dentist, veterinary, etc.)and uses only medical <br /> gases. <br /> DC. This business operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. OYes Mo Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. ❑Yes loo 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 California Health and <br /> Safety Code. I understand that if i own a facility or property that is used by tenants, that 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. <br /> I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge. <br /> Owner or r' e Agent: t� <br /> X r Date: r �'yo�—llat <br /> rint ame - <br /> XTitle:_ 00/U U <br /> Signature <br /> F/ApplicaUonsForms&Handouts/PlanningAppOcabons/Business License(Revised 02-2415) <br /> Page 4 of 6 <br />