Laserfiche WebLink
?A1700051 <br /> San Joaquin County <br /> DIRECTOR <br /> Environmental Health Department DonnaHavan.REMS <br /> 1566 E Hazelton Avenue PROGRAMCOORD3>kA?cRs <br /> ' Stockton, California 95205 <br /> , :1etf Carrrie:�ce.Bt�H`a.�.ur <br /> Kasay rvtey. >~ <br /> Website: yr Av.sjgov.orglehd Linda Tii We,ME5HS <br /> r'*ttano: 209 46 -342#1 Rudney.Bfrad ,q6:H8 <br /> ) Adrierni'rat c lsaes,r#_k&IS <br /> Fax: (209)469-3433 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for eacti business name andlor address ih fan Joaquin Counly, <br /> Business Meme. <br /> 2 L Jam. /v.c Y r —Telephone: GJ'lo �s l <br /> Business Site Address: � <br /> Mailing Address(if different.fro[n above).. 94 <br /> Business Owner(s)Name: 4& Telaphonet ��lo <br /> Business Owner Address: <br /> L <br /> t Fire . trict �t(L� t �1�cr Yin Iti1G'�C►'��O`� <br /> Nature of Business: Y_v I <br /> Q?. c Yes XNo Dews 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 forme. <br /> YesNa Does your business generate,treat,or store a hazardous waste in any Uuanti (used oil. <br /> used antifreeze,waste solvent,etc.) <br /> If your answer is"No"to bath.questions in 01,please print,sign,and date the bottom of this tvrtn'an,d return to the address above. <br /> Q2, w Yes ^l�Jo Dues your business handle a hazardous material, or a mixture containing a hazardous <br /> X` material, in a quantity equal to or greater than 55 gallons,560 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 or the following conditions that apply to your business! <br /> aA. The hazardous materials handled by ibis business are contained sotely in a consumer <br /> product packaged for direct distribution to and use by the general public. <br /> E3 This business operates a farm for purposes of cultivating the soil,raising or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. C Yes YNo Does yoirt`.business handle an Acutely Hazardous Material? See definition on page 2. <br /> 04. r,Yes �No is your business within 1,000 feet of the outer boundary of a school?(Grades K-1 2j <br /> I have read the information cin this form and understand my requirements under Chapter 6.95 of,the California Wealth and <br /> Safety Code(NSC). I understand that if I own a facility or properly that is used by tenants,it is.my responsibility to notify tine <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 /> eery knowledge. <br /> Owner or Authorized Agent: <br /> Print Name /A � � /� tate: / 2 �b <br /> s <br /> 5ignatura_ Title: <br />