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r^t;,Qlllid,C � VAN J O A Q V I 1 1 <br /> Environmental Health Depar•firn�o��: <br /> ��� fir., �~•' ,Ar <br /> `f C O U ISI Y <br /> Greatness grows herr. <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and;or address in San Joaquin Cou-ty. <br /> Business Name: _J� __qAM - -12r�C L 1`U� vG Telephone: <br /> Business Site Address. <br /> Iskailing Address(if difierenl from above): 5 _ IV0 1, <br /> Business Ovmer(s)Name: t✓1 AN �3 IT 1 YV Telephones: 2 O Cl• 9� <br /> r � —� <br /> Business Ovmer Address: ��.�,7 � 1 1� —T e.. _-- <br /> Nature of Business: •V RiAiAL';•rj r-ire District: 1 LY ' <br /> 01, L Yes KNO Does your business handle a hazardous material in any auanlity at any one time in the yea? <br /> See the definition of hazardous:material on page 2 of this torn. <br /> c Yes 01 No Does your business generate,treat,or store a hazardous waste in any guantity7(used oil, used <br /> antifreeze,waste solvent, etc.) <br /> If your answer is"No"to both questions in Q1,piease 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 b isinass7 <br /> If"Yes', check any of the following conditions that apply to your business: <br /> Li 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 c No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes r No Is your business within 1,000 feet of the otter boundary o;a school? (Grades K-12) <br /> 1 have read the informabor 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 ora n 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 Occipancy or beginning of operatiors. I declare under the <br /> penalhy of perjury that the Informatior provided on this disclosure survey is true ane accurate to the best of my knowledge. <br /> If you answered"Yes'to Question 2, please go online to cers.cz:leaa.ca.gov to s.:bmit your hazardous materials information. <br /> Owner or Authorizes Agent: <br /> Print Name: Date: C%' j 0 3 <br /> Signature �f`�!G`r�1 i�i i,tle: <br /> 1RRR F Ha7Plrnn AvPnmq I Stnnktnr C;alifnrnia 9520b I T 209 468-3420 1 F 209 464-0138 1 vrw o.sicehd.com <br />