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San Joaquin County <br /> p,hq IN.,,c bIRECTOR <br /> Environmental Health Department <br /> Donna Heran,REHS <br /> 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> Stockton, California 95205 Robert McClellon,REHS <br /> Jeff Carruesco,REHS,RDI <br /> Kasey Foley,REHS <br /> <il oc?ri <br /> Website: www.sjgov.org/ehd Linda Turkatte,RENS <br /> Phone: (209)468-3420 Rodney Estrada,REHS <br /> Fax: (209)468-3433 Adrienne Ellsaesser,REHS <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County, <br /> Business Name: Trajen Flight Support, LP dba Atlantic Aviation Telephone: 209-982-1622 <br /> Business Site Address: 6364 S. Lindbergh Street, Stockton CA.,95206 <br /> Mailing Address(if different from above): 1460 Breezy Way,Spring Hill,FL 34608 <br /> Business Owner(s)Name: Brian Nusser Telephone: 209-982-1622 <br /> Business Owner Address: 6364 S.Lindbergh Street,Stockton,CA 95206 <br /> Nature of Business: Fixed Base Operator Fire District: Montezuma <br /> Q1. d Yes o No Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on page 2 of this form, <br /> r(Yes o No Does your business generate,treat,or store a hazardous waste in any quantity?(used oil, <br /> used 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. e Yes o No Does your business handle a hazardous material, 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 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 /> u A. The hazardous materials handled by this business are contained solely in a consumer <br /> product packaged for direct distribution to and use by the general public. <br /> C B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. ❑Yes 6 No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes J(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 <br /> Safety Code(HSC). I understand that if I own a facility or property that is used by tenants, it is my responsibility to notify the <br /> tenants of the requirements which must be mel prior to issuance of a Certificate of Occupancy or beginning of operations. I <br /> declare under the penalty of perjury that the Information provided on this disclosure survey Is true and accurate to the best of <br /> my knowledge. <br /> Owner or Authorized Agent: <br /> Print Name: Russell Stark Date: June 30,2020 <br /> Signature: Title: Airport Director <br /> 1 <br /> R.I..d 11/07712 <br />