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U ? !�. , COUNTY OF SAN JOAUIN Environmental Health Department 1868 E Hazelton Avenue Stockton , California 95205 Telephone ( 209 ) 468 - 3420 aLJfioR. FAX (209 ) 46 &3433 Website : www . sjgov . org /ehd HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the information on the reverse side before completing this survey form . A separate survey for each business name and/or address in San Joaquin County is required . Business Name : " k L040 c:R PAcl, c4o yv - Business Owners Name : 1 '� i Telephone : ( ) C �- � �.1 �.. ? 11.3 � � Business Address : i-� J Mailing Address ( if different from above ) : Nature of Business : Fire District: Q1 . ❑ Yes kNo Does your business handle a hazardous material in any quantity at any one time in the year? See the definition of hazardous material on the back of this form . If your answer is No , " go to Question 4 . Q2 . ❑ Yes kNo Doeso-ur business handle a hazardous material or a mixture containing a hazardous material in a Y g quantity equal to or greater than 55 gallons , 500 pounds , or 200cubic feet at any one time in the year? If "Yes , " how long have you handled these materials at your business ? If "Yes , " check any of the following conditions that applies to your business . ❑A. The hazardous materials handled by this business is contained solely in a consumer product , packaged for direct distribution to , and use by, the general public . ❑ B . This business is a health care facility (doctor, dentist , veterinary, etc . ) and uses only medical gases . ❑ C . 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 reverse side of this form . 4 . ❑ Yes ® No Is our business within 1 000 feet of the outer boundary of a school (grades K- 12 ? Q Y Y (g ) I have read the information on this form and understand my requirements under Chapter 6 . 95 of the California Health and Safety 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 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 . Owner or Authorized Agent : � X N -� � � � � Date : Print Nam 1ZX t Title : 0 �e- Signature