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CLU.IN <br /> L� .y <br /> Cq�%F ORN`P <br /> COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> Telephone(209)468-3420 <br /> FAX (209)468-3433 <br /> Website: www.sjgov.org/ehd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business name <br /> and/or address in San Joaquin County is required. <br /> Business Name: Skoxbuck/s — lv%s�de ey-5+iro 6in-Pt�A4 r74oro 42.107 <br /> Business Owner(s) Name: 59e4aft I he. Telephoner <br /> Business Address: &A45 polci;\L Avewe Lt�...t.ADA C6 $16?-01 <br /> Mailing Address (if different from above): <br /> Nature of Business: 56rbuaf'� Fire District: 6 i IF --SlCtk b(1 <br /> Q1. CYes )INo Does your business handle a hazardous material in any quantity at any one time in the year. See the <br /> definition of hazardous material on the back of this form. If your answer is"No," go to Question 4. <br /> Q2. OYes XNo Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br /> equal to or greater than 55 gallons, 500 pounds,or 200c 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 /> OA. The hazardous materials handled by this business is contained solely in a consumer product, packaged for <br /> direct distribution to, and use by,the general public. <br /> OB. This business is a health care facility(doctor, dentist,veterinary, etc.) and uses only medical gases. <br /> CC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3. CYes XNo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes WNo 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. I understand that if I own a facility or property that is used by tenants,that 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 survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agen <br /> X Date: lb-is. 20 <br /> P Int Name <br /> X Title: Af hi+ec+ <br /> SI ure <br /> F:Wpplication Forms&Handouts\Building Application Checklists\Check List Commercial Building Pennit.doc(Revised 01/08/2016) 3 of 4 <br />