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?A1700051 <br /> San Joaquin County <br /> L1iAECfi'OFt <br /> ,, -- Environmental Health Department oonnaHem€,REHS <br /> 1868 E Hazelton Avenue PROGRAM COORt I.ATURS <br /> Stockton, California 35205 JeffCanuatim, HS. <br /> .iaif t;arru �cfsHs.Pmt <br /> evwyf St y:REHS <br /> Website: ww.sigov.org/ehd tintteTiii?t� <br /> `+ Phone. (209)466-3420 R-adneyEsirada r z�' <br /> Fax: (209)468.2433 Fdrnireisaes :*t >S <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County. <br /> L cr i/L r r Telephone: <br /> Business Name: hf. �. �--� <br /> Business Site,address: <br /> Mailing Address(it dif ereht.from above). Cr<h" q6� <br /> Business Ownar(sy Name- L t' T�phone. L;In LSA 2 7 _ <br /> L <br /> Business Owner Address: r,4 <br /> Nature of Business: Y v ` _ Fire 41ictl <br /> Q?. a Yes XNo Does your business handle a hazardous material in any quantity at any one time In the <br /> yoor? See the definition of hazardous material on page 2"of this form,. <br /> Yes /�/No Does your business generate,treat,or slore a haizardous+nraste in env quantity?(used oil, <br /> used antffreeze,waste solvent,etc.) <br /> If your answer is"No"to both questions in 01,please print,sign,and date the bottorn of this form arta return to the address above. <br /> Q2, Z yes �(V0 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 cutx c.fact 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 P yopir business: <br /> o A. The hazardous materials handled by this business are contained solely in a consurner <br /> product packaged for direct distribution to and Lisa by the general public. <br /> B:. This business operates a farm for purposes of cultivating the soil. raising or harvt stv,g an <br /> agricultural or horficulturat commodity. <br /> Q . c yes ,/No Does your business dandle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. 5.yes /No is your business vrlthin 1,000 feet of the outer boundary of a school?(Grades K-?z) <br /> I have read the information on this foals and understand my requirements under Chapter 6.45 of the California Health and <br /> Safety Cods(HSC). I understand that if€ own a facility or properly that is used by tenants,it is my responsibility to notify tt" <br /> tenants of the requirements which must be met prior to'issuancs 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 t+:nowtedge. <br /> Oyster or Authorized Agent: <br /> PrinfNannix LLiI.1� 1 LZ bate. <br /> Signature. <br /> Z Z. Title. <br />