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<br />A separate surrey form is required for each business name and/or address In San Joaquin County.
<br />Business Name:
<br />7elephone:D��.• !'
<br />Business Site Address: (•F'e t ,QrL±' & ,t•-c�' ''E'`�- �.� Qi S �.�r�
<br />Mailing Address (if different from above); e i to t t, Kfi� l yLr r�_/.. �; S• 3
<br />Business Owner(s) Name.,rr �s��W I�.n�� Telephone: -7 91 7—' Rae, C',
<br />Business Owner Address: _ -M CV(-S-t—eAt '5;+- . Wit t-4,4vl, , iy"iA ' 014 T3
<br />Nature of Business: } j-ap _ Fire District: I L Ai). "v / �`"i �a 6•�" �"� Gv
<br />Q1. Pes a No Does your business handle a hazardous material in aU au@ntity at any one time in the
<br />year? See the defSrtition of hazardous material an page 2 of this form.
<br />)(Yes o.No Does your business eni (mss 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 />02. KYes a 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, $00 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? !I 'I A=5
<br />If "Yes", check any of the following conditions that apply to your business:
<br />o 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 />03. This business operates a farm for purposes of cultivating the soil, raising or harvesting an
<br />agricultural or horticultural commodity.
<br />Q3. a Yes ^O�No Does your business handle an Acutely Hazardous Material? See definition on page 2.
<br />04. a Yes �LNo 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 roulrements under Chapter 6.95 of the California Health and
<br />Safety (Ade (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 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. Nfievli2Sf" ��Lr°t/.pLta�ii►�VtiE+e
<br />Owner or Authorized{'gent: 6A 14'S m per, 6 &?-
<br />Print Name: 5 n i
<br />0� ' Q V%jr.tA:2) Date: j i 13
<br />Signature: Title:
<br />P64mA1 W07112
<br />San Joaquin County
<br />°DIRECTOR
<br />o
<br />Environmental Health Department
<br />Donna Heran, RENS
<br />Z
<br />1868 E Hazelton Avenue
<br />PROGRAM COORDINATORS
<br />„
<br />Stockton, California 95205
<br />Robert McOellon, REHS
<br />JeffCatruesco, REHS, RDI
<br />Kasey Foley, REHS
<br />4 ®
<br />Website: ws► W.sj9oY.or91ehd
<br />Linda Turkatte. REHS
<br />Phone: (209) 468-3420
<br />Rodney Estrada, REHS
<br />Adrienne Ellsaesser, REHS
<br />Fax: (209) 468-3433
<br />• - -.11-" +r - '
<br />A separate surrey form is required for each business name and/or address In San Joaquin County.
<br />Business Name:
<br />7elephone:D��.• !'
<br />Business Site Address: (•F'e t ,QrL±' & ,t•-c�' ''E'`�- �.� Qi S �.�r�
<br />Mailing Address (if different from above); e i to t t, Kfi� l yLr r�_/.. �; S• 3
<br />Business Owner(s) Name.,rr �s��W I�.n�� Telephone: -7 91 7—' Rae, C',
<br />Business Owner Address: _ -M CV(-S-t—eAt '5;+- . Wit t-4,4vl, , iy"iA ' 014 T3
<br />Nature of Business: } j-ap _ Fire District: I L Ai). "v / �`"i �a 6•�" �"� Gv
<br />Q1. Pes a No Does your business handle a hazardous material in aU au@ntity at any one time in the
<br />year? See the defSrtition of hazardous material an page 2 of this form.
<br />)(Yes o.No Does your business eni (mss 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 />02. KYes a 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, $00 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? !I 'I A=5
<br />If "Yes", check any of the following conditions that apply to your business:
<br />o 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 />03. This business operates a farm for purposes of cultivating the soil, raising or harvesting an
<br />agricultural or horticultural commodity.
<br />Q3. a Yes ^O�No Does your business handle an Acutely Hazardous Material? See definition on page 2.
<br />04. a Yes �LNo 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 roulrements under Chapter 6.95 of the California Health and
<br />Safety (Ade (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 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. Nfievli2Sf" ��Lr°t/.pLta�ii►�VtiE+e
<br />Owner or Authorized{'gent: 6A 14'S m per, 6 &?-
<br />Print Name: 5 n i
<br />0� ' Q V%jr.tA:2) Date: j i 13
<br />Signature: Title:
<br />P64mA1 W07112
<br />
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