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RECEIVED <br /> 1)1) 1) <br /> San Joaquin County <br /> o�QU.+N c EP 0 5 LL1J q DIRECTOR <br /> Environmental Health Department Donna Heran,REHS <br /> 2�.�� �• N JOAQUIN COUNTY <br /> N� { NVIRONMENTAI 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> a. TH DEPARTMENT Stockton California 52 Robert McClellon,REHS <br /> .. � . .+� li rn�a 9 05 <br /> Jeff Carruesco,REHS,RDI <br /> Cq ..., Kasey Foley,REHS <br /> <<FoRa Website: www.sjgov.org/ehd Linda Turkatte, 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: �$a. ►rJ>Dll�l�'�� l<- Telephone:( �) 967 - d� <br /> Business Site Address. Z3 Z,< NJt=�' '-4AUi_ why '911>c)—'CayJ . CA - 95'2CG <br /> Mailing Address(if different from above): S1aYti� <br /> Business Owner(s)Name: Telephone: <br /> Business Owner Address: ` _e 6s <br /> trNature of Business: AVS VA0*11)z Walaw PagAWCc <br /> Q1. 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 /> �Kyes ❑ 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 Q1,please print,sign,and date the bottom of this form and return to the address above. <br /> 02. Xyes ❑ 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? Z �l PS <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 /> ❑ B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes �.jVo Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes Avo 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 (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 Agent: <br /> Print Name: SC— � �Q �y�f Date: <br /> Signature: Title: as �e AV'60` <br /> 1 <br /> Revised 11/07/12 <br />