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�� �� �� �� X� ��� �~� <br /> �^��� � ° �_ � �� K~� ' <br /> JUL73 7070 <br /> »\ <br /> ENVIRONMENTAL HEALTH_amJoa�uiMCounty <br /> ES <br /> DIRECTORpERK |T/- ^Envir0n0ental Health Department <br /> o,,n,He,q^,ns*s <br /> 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> Mc�v sno <br /> , � ���m�������, ����i������ �5��� Robertno".n <br /> ' Jeff oavueum,ilRDI <br /> xosmvFoley,RsHo <br /> Website: v«mxw.sigov.mrg/ehd Linda rumoxe,nEnn <br /> Phone: (2U9)4G8-�42O n^uneyEstrada,nsxS <br /> xo^c^nvsosa^:ma.esHa <br /> Fax: (209)468-3433 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County, <br /> Business Name ' <br /> euoineooSite Audmaa: <br /> Mailing Address(iruiMo,nnt fr9oR abo�e): <br /> Business Owner(s)Name� Telephone: �2 <br /> Business Owner Address: yj�-D��Oflill 01g, qoo�-J` <br /> Nature of Business: Fire District� ll —0,P I <br /> Q1 ;K Yes o No Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition uf hazardous material vnpage 2ofthis form. <br /> NYeu umo Does your business generate,treat,o,store ahazardous waste in any quantity?(used oil, <br /> used antifreeze,waste solvent,eto.) <br /> /,your answer/v^wv''mboth questions mo1'please print,sign,and date the bottom v,this form and return mthe address above. <br /> 02 Yes XNo Does your business handle s 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 inthe year? <br /> /f^vev'. how long have you handled these materials atyour business? <br /> If"Yes".check any o/the following conditions that apply+nyour business: <br /> oA The hazardous materials handled by this business are contained on|e|y in o consumer <br /> product packaged for direct distribution mand use uythe general public. <br /> oB This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural u,horticultural commodity. <br /> O3. oYoa gNo Does your business handle anAcutely Hazardous Material? See definition nnpage 2 <br /> 04. oYce �No |oyour business within 1.O0Ofeet of!heouter boundary ofuschool? (Grades x'1x) <br /> | have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code (HSC). | understand that if| own o facility or property that is used by tenants, .t is my responsibility to notify the <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. | <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 orAuthorized Agent: <br /> 19. 2o <br /> | k� <br /> Print <br /> ��namm� ' Title: ' " "'^ <br /> 1 <br /> "=u.d"107o <br />