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� "c SQN�,� OQQU , l� Environmeni d Health Department <br /> v 0t'" ` ` COU N T Y <br /> cg e Greatness grows here. <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: iD hCL►'VVI 1�'C: 1D GC - 377 <br /> e--) tLC Telephone: (V16) T <br /> Business Site Address: l23 Z Q :!f Y e + , a ✓ff P lct)r f At/z MPt7 7�_ <br /> Mailing Address(if different from above): AM F , L ?i�lP <br /> Business Owner(s) Name: Inn Telephone: ,^y�l /wSC�� �0 <br /> Business Owner Address: c� 'V. I LVl (/� s6jL-N "I J� <br /> Nature of Business: , k, 6v1 Fire District: <br /> Q1. /es o No Does your business handle a hazardous material in any quantity at any one time in the year? <br /> See the definition of hazardous material on page 2 of this form. <br /> ❑Yes ❑ No Does your business generate,treat,or store a hazardous waste in any quantity?(used oil, used <br /> antifreeze,waste solvent, etc.) <br /> If your answer is" o"to both questions in Q1,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2. es ❑ No Does your business handle a hazardous material,or a mixture containing a hazardous material, <br /> in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time <br /> in the year? <br /> If"Yes", how long have you handled these materials at your business? N 1�- <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 product <br /> 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 ax_o Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes CLW/ 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 Safety <br /> Code(HSC). I understand that if I own a facility or property that is used by tenants, it is my responsibility to notify the tenants of the <br /> requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> If you answered"Yes"to Question 2, please go online to cers.caiepa.ca.gov to submit your hazardous materials information. <br /> Owner or Authorized Agent: <br /> Print Name: �ilJh� �J��'G� Date: <br /> Signature: Title: Ojo0t f- <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />