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San Joaquin County <br /> �QU r N DIRECTOR <br /> Environmental Health Department Donna Heran,REHS <br /> `rpti <br /> 04' 1868= 'Y 1868 E Hazelton Avenin PROGRAM COORDINATORS <br /> Stockton, California 95205 Robert McClellon.REHS <br /> Jeff Carruesco,REHS,RDI <br /> Kasey Foley,REHS <br /> 0 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: ` <br /> - 11•J� �UCIFT I 1 re- Telephone: ZDq <br /> Business Site Address: 1'o�2.� -�-�{�Y��` �- �'t�N�S � , 2-1-77 <br /> Mailing Address(if different from above): i- IA X <br /> Business Owner(s)Name: Telephone- o-1 -" Cl 7 Z.-- OVO I <br /> Business Owner Address: ��7/Q lJ� lf�l�-�S ( ,est - �5 7 <br /> Nature of Business: -�"r`��/ Q-VlLt°.r,, LIwNiYt N�" Fire District: "-S"t4r..a J4-V,:7t,1t,�,j <br /> i <br /> Q1. o Yes 11(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 /> ❑Yes XNo Does your business generate,treat,or store a hazardous waste in any quantity?(used oil, I <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 /> Q2. ❑Yes A 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 /> n B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural.or horticultural commodity. <br /> Q3. ❑Yes )(No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. D Yes )4 No 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: (�19$a�'1• �/! '/al Z U[�`/✓� Date: <br /> Signature: T le: Owlye4l� <br />