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SANJOAQUIN Environmental Health Department <br /> 0 J N 7Y_- <br /> - :7Pd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separale siurwey form is requlted tom'each business narnx andfor ad&usz in San Joequtn County. <br /> 1dEl' Schaaf Dairy #3 _Tetf pp honeL (209) 830-39 #7 <br /> �tt>� sti Slip rd*tss: 3775 Murphy Road. E calcrx C 95320 - <br /> Val Ma address(If different from dhcvv0, — <br /> Sw8iness Qwrrzdr(s)tdartia: Jahn Vander Schaaf Telephone-, <br /> Business Owner Address- <br /> Natu sof®ti In ss Dairy Mira 10i.,Vict. Co'IBga1FIf1e dire DISdt`ict <br /> 0 _ w Yea ;Nn does your hiisiness harufle a hoxardnus nwiaHal ars g�f at any we rune in the year? <br /> See•he defIrilflon of hazardnus material on page 2 of this fnrm. <br /> Pi Yes C No Does your businestti garterais,treat ai'6:twa a 1ramrdcus waste lrr tiortggarltityT fused off,u-sad <br /> ar,Wreeze,wosjr!Volvo nt,etc.) <br /> If your answor is"NO to b0h quagtt rra in Qi.ptaaea print,aFpn,and data 1A6 bait m of thla form and return in ttsb addrea&acbava. <br /> 02- oh'Yes No DMS your bd:iJnoxs herdic whazardmk sr,meteriai,or a mwore wnwinhrog a'hazerctatis material, <br /> in ra quantity equw to or grunter than 45 sallvs.500 pounds,or 200 whit,feai at any orae 1�rle <br /> lrr fhe year? <br /> Since dairy Vvied' <br /> If'Yes",hc�ry Ibrrg trot}youItemdted tht: .r�dlbrials at yCsurta�usines�7 <br /> I r"Yes`, nc k Ari y or the forlowirrr wfrClvDn,s otw apngy%ygpr wsin"!S: <br /> A. ThB Iwardaus rrralarials handled by tttis businsss are contalniad sdoly irr a zonsurmr proclrat� <br /> p$ sad lurdiract disc 4L*.on to arrd vwt by the go-feral Ipu ab <br /> e. Phis bu+elr+vHs apeM184 R terra fuer PWPr rs" of CLj4ivat rig tfte chili C115iig+ar hprumating arl <br /> agrv�ul'turt+l <br /> or hoMicullural ca mmodily. <br /> Q3, h Yes `Flo does yourbusirws handle an Auvtetyr HEvwy ous lafABt:s'irif? See rtafnition on pager 2. <br /> 04. ri Y'e±s a tNra IS yCKrr tir,sbno c rer0T[n 1,00n fret of the airier boundary of a stbool?(Grodae K-12]� <br /> I Fislwrwd ft Inrormailon on chis form and under miand roy-requirements rumor Chapter 6-95 of tho Cil-forma Heaklitr and 5aafeky <br /> Code(W). I undersfernd that#I own a k�tiiity of property final is used bye tenEnts.f is my ru sParrs4bi y to r>o*thO tenants Of Cne <br /> requirernents W ch must be Trot prtorto iitmuon.ce of a Ceilftitata of Oocuparrcy pr beg P�n[r%q df opo a4arrs 1 d8Glaro unddr 1rs <br /> pun8l y-of per ury that ft InfurMatloan ptoVided on this t tis sure murvey Is the acrd accurate tQ the best of my knowtodge. <br /> IfYOU 811sivared'Yes*10 Questioro 2., pfeat�e gn rrrline to c o,�s;caler.a.� .;.�rnrtt�.sub.mlt}rnurtrgzerdous miaterea informaMn- <br /> 0*ner or Autftorized Agent; <br /> IIt <br /> Print N. me: <br /> Si�rraturr�• �. ____._T�'�'� __ Tt;te: _ ,�:1 a,'� � .., <br /> y <br /> 480 E. Hi�zehon Averrwe I Stoc1cto%CaRlbrniar 95205.1 7 20 40'8-34201 F 229 464-0138 1 vruw.s]cehd,u.am <br />