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SAN J O A Q U I N Environmental Health Department <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. Complete Welders Supply Telephone: 209-462-3086 <br /> Business Site Address: 1549 North Broadway Stockton, CA 95205 <br /> Mailing Address(if different from above): P.O. Box 2516 Napa, CA 94558 <br /> Business Owner(s) Name: Mike Kowaleski Telephone: 209-462-3086 <br /> Business Owner Address: 101 Camino Dorado Napa, CA 94558 <br /> Nature of Business: Retail Sales of Welding Supplies and gaW Fire District: 1S1-5 t p A <br /> Q1. Yes No Does your business handle a hazardous material in any quantity at any one time in the year? <br /> See the definition of hazardous material on page 2 of this form. <br /> Yes OF, Does your business generate,treat,or store a hazardous waste in any quantity?(used oil,used <br /> 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. _i Yes ❑ No Does your business handle a hazardous material,or a mixture containing a hazardous material, <br /> in a quantity equal to or greater than 55 gallons, 500 pounds,or 200 cubic feet at any one time <br /> in the year? <br /> If"Yes", how long have you handled these materials at your business? A <br /> If"Yes", check any of the following conditions that apply to your business: <br /> )(A. The hazardous materials handled by this business are contained solely in a consumer product <br /> 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 /> Q3. CXe s 010 Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. c Yes YNo 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(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 <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 /> If you answered"Yes"to Question 2, please go online to cers caleoa ca.goov to submit your hazardous materials information. <br /> Owner or Authorized Agent: <br /> n <br /> Print Name: If S 0 0-7 er Date: 6 I to /goao <br /> Signature: Title: <br /> 1656 E. Hazelton Avenue Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />