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-+= _ F Envi€onir entc � Hea[tt`� Department <br /> �: . <br /> = 4• :w` C O U Ind T Y <br /> eatness gross ?;tri. <br /> HAZARDOUS MATEREALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County. <br /> Business Name. l i �ik� .t-�.' Url1 `J;,•r„` ��� �� Telephone: <br /> Business Site Address: �k2et� PiGG�T���� �``� P� �E<r. S��k O'I�Z•t7� <br /> e � <br /> Mailing Address(if different from above): \1Ci F LK <br /> Business Owner(s) Name: Ll n, F\M Telephone: <br /> Business Owner Address: e,Uar NL- <br /> Nature of Business: �.V�\ �L ' �`vl�� � Fire District 5 � <br /> a a a <br /> Q1: ❑ Yes rNo 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 VNo 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"No”to both questions in Q1,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2. o Yes o No Does yourbusiness handle a hazardous material,ora mixture containing a hazardous material, <br /> in a quantityequal to or greaterthan 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? <br /> If"Yes",check any of the following conditions that apply to your business: <br /> o 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 o No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. in Yes o No Is your business within 1,000 feet of the outer boundaryof a school?(Grades K-12) <br /> I have read the information on this form and understand my requirements under Chapter 6.95 of the Califomia 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 cern calega.ca.4ov to submit your hazardous materials information. <br /> Owner or Authorized Agent: <br /> �� <br /> Print Name: a <br /> Date: <br /> Signature: C� Title: m . , <br /> C� <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wwv✓.sjaehd.com <br />