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SAWJOAQUINnvironmental Health Department ------ C O U N T Y - HAZARDOUS MATERIALS DISCLOSURE SURVEIL A separate survey form is required for each business name and/or address in San Joaquin County , Business Name : Waterloo Morada Fire District Station 2 Telephone : (209 ) 931 - 3107 Business site Address : 4946 E Eight Mile Road , Stockton CA 95212 aMailing Address ( if different from above) : 6925 Fopplano Lane , Stockton CA 95212 Business Owner( s) Name : IJVaterloo Morada Fire District Telephone: (209 ) 931 - 3101 Business Owner Address : 6925 E Fopplano parte , Stockton CA 95212 Nature of Business : Fire Station Fire District: Waterloo Morada FD Q1 . ❑ Yes m No Does your business handle a hazardous material in any quantity at any one time in the year? See the definition of hazardous material on page 2 of this form . D Yes ❑ No Does your business generate , treat, or store a hazardous waste in anV quantity ? ( used oil , used antifreeze, waste solvent, etc. ) If vour answer is " Edo" to both questions in Q1 , please print, sign , and date the bottom of this form and return to the address above . 02 . n Yes ❑ No Does your business handle a hazardous material , or a mixture containing a hazardous material , n a auantity equal to or greater than 55 gallons , 500 pounds , or 200 cubic feet at any one time in the year? f `Yes how long have you handled these materials at your business? If " Yes" . check any of the following conditions that apply to your business: A . The hazardous materials handled by this business are contained solely in a consumer product packaged for direct distribution to and use by the general public . B . This business operates a farm for purposes of cultivating the soil , raising or harvesting an agricultural or horticultural commodity . Q3 . Yes ❑ No Does your business handle an Acutely Hazardous Material? See definition on page 2 . Q4. ❑ Yes ❑ No Is your business within 1 , 000 feet of the outer boundary of a school ? (Grades K-12) I have read the information on this form and understand my requirements under Chapter 6 . 95 of the California Health and Safety 'C' ode ( 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 requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations . 1 declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge . If you answered "Yes" to Question 2 , please go online to cers . caleoa. ca . aov to submit your hazardous materials information . Owner or Authorized Agent: Print Name : � TE - WAR T * r (`� i �=> Date : 3/20/2020 Signature : Title. 0 VY 1