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CJS ZC cl " <br /> SAN J U A Q U I N Environmental Health Department <br /> COUNTY <br /> Greatness g,ows 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 /> �'� n�l "k."� ��G! �L� /� .Tele hone: <br /> Business Name:__. t � p j -� � " .3 14 <br /> Business Site Address: <br /> Mailing Address(if different from above): Fp <br /> Business Owner(s) Name: J u(� DC.V � 1 �� Telephone: � 669- q�3 6 <br /> Business Owner Address: I of f'n A y 19t—C k L—A N& I+€K-C (,kU S, C� C1 L4>�Lf7 <br /> Nature of Business: C " USA -S H Fire District: S PTN j'()A Q(,k(pj <br /> Q1. ❑Yes `� 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 Vo 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. ❑Yes ❑ 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? <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 ❑ No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑ Yes ❑ 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 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 surrey is true and accurate to the best of my knowledge. <br /> If you answered "Yes"to Question 2, please go online to cers.caleoa.ca.gov to submit your hazardous materials information. <br /> Owner or Authorized Agent: , / n, <br /> Print Name: UlK tit D� y S ( rJ 61 W Date: v' <br /> Signature: C--� F Title: til) G <br /> ED <br /> JAN 0 2 2020 <br /> 1868 E. Hazelton Avenue I StocWV.1KQN3AEN AUREXLTPP 468-34201 F 209 464-0138 waruw.sjcehd.com <br /> PERMIT/SERVICES <br /> T9,0519 -70a -10A - S3,0 Chef-o1(_ee, <br />