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COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> Telephone(209)468-3420 <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 /> Narne: East Bay Tire Company <br /> Business Owner(s) - — <br /> Name: George & Joseph Pehanick Telephone: 707-437-4700 <br /> Business <br /> Address- 2807 State Hwy 99 West Frontage Rd., Stockton, CA 95215 <br /> Corporate Address: 2200 Huntington Dr., Unit C, Fairfield, CA 94533 <br /> Mailing Address(if different from <br /> above) <br /> Nature of --- --- <br /> Business: Automotive Sales and Service Fire District: Montezuma Fire District <br /> Q1. XOYes ONo Does your business handle a hazardous material in any quantity at any one time in the year? See <br /> the definition of hazardous material on the back of this form. If your answer is No," go to Question 4. <br /> Q2. XOYes ONo 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? Januaryt017 <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> OA. The hazardous materials handled by this business is contained solely in a consumer product, <br /> packaged for direct distribution to, and use by, the general public. <br /> OB. This business is a health care facility(doctor, dentist, veterinary, etc.) and uses g_nl medical <br /> gases. <br /> OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes X ONo Does your business handle an acutely hazardous material? See definition on reverse side of <br /> this form. <br /> Q4. ❑Yes X ONo Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 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. I <br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> X Janet Sullenger Date: 1� <br /> riRt�Naa ne <br /> X Title: Accounting Manager Corporate Office <br /> Sig re <br /> F/ApplicationsForms&Handouts/PlanningApplications/Business License(Revised 02-24-15) <br /> Page 3 of 4 <br />