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��Dj����i� ����n�'� <br /> � umsnron <br /> Environmental Health Department Donna Heran,REHS <br /> 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> Robert Mcnlelmn. <br /> nsHsStockton, California 95205 <br /> Jeff onnuesc^.nsHs.RDI <br /> . xa� pax� <br /> — 'nsHn <br /> V���� ���g����hd m�r�u�,ns� <br /> -- Rodney Estrada, '�s*n <br /> Phone: (2Q3)468-342V Adrienne enour.nsns <br /> Fax: <2090488'3433 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County. <br /> L~ <br /> Business Name: - <br /> Ile <br /> Business Site Address: <br /> Mailing xuu (if different on u ) <br /> -usiness-----`—N--: <br /> Business Owner <br /> Nature mBusiness: Fire District: <br /> Q1 nYeaNo Does your business handle o hazardous material any one time in theyoan See the definition ofhazardous material onpage zofthis form. <br /> oYea ��No Doeayourbusineosgeno�to.tnaat.o,em�ahozw�nvowasta�al1q���?(uoednii <br /> '' used antifreeze,waste solvent,em.) <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 /> Qz ii Yes No Does your business handle e hazardous mato,ia|, or a mixture containing a hazardous <br /> material, in a quantity equal to or greater than 55 gallons, 500 pounds,or 200 cubic feet at <br /> any one time inthe year? <br /> |f^Yeo^. how long have you handled these materials atyour business? <br /> \f''ven".check any vf the following conditions that apply toyour business: <br /> A. The hazardous materials handled by this uuamaao are contained oo|o|y in a consumer <br /> product packaged for direct distribution mand use bythe general public. <br /> oe. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural v,horticultural commodity. <br /> Q3. ovua ><No Does your business handle enAcutely Hazardous Material? See definition oopage a. <br /> Q4. oYos )(No |syour business wi�m1.00n� � � <br /> e/o� eou�o,uoundaofauchoo|?(em � <br /> (Grades K-1 <br /> | have read the information on this form and understand my requirements under Chapter s.e5 of the California Health and <br /> Safety Code(HSC). | understand that if own ufaciuty or property that is used by tenants, it is my responsibility to notify the <br /> tenants ofthe requirements which must bemet prior missuance nroCertificate of Occupancy orbeginning n,operations. | <br /> declare under the penalty orperjury that the information provided on this disclosure survey is true and accurate to the best of <br /> my knowledge. <br /> Owner orAuthorized Agent: <br /> pn w : <br /> Signature: Title <br /> Revised 11,07h2 <br />