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COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 eV W CANNED <br /> Telephone (209)468-3420 <br /> FAX (209)468-3433 <br /> Website: www.sjgov.org/ehd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business <br /> name and/or address in San Joaquin County is required. <br /> Business f9-0 <br /> Name: TO 1' 171 Of, 770C1,60 t"AUC C. <br /> Business Owner(s) <br /> Name: /(,'fan + r)1 / �H P Jl CT <br /> elephone: <br /> Business // C�'j <br /> Address: 522 r 1, � ' t� S rire f Tra&q 1./� ( z <br /> Mailing Address (if different from <br /> above): <br /> Nature of <br /> Business: ! u�C��) UC/z ��, Fire District: , f—Ci Ct j <br /> Q1. ❑Yes �SNo Does your business handle a hazardous material in any quantity at anyone time in the year? See the <br /> definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2. ❑Yes 'P}No Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at any one time in the year? <br /> If"Yes," how long have you handled these materials at your business? <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> ❑A. The hazardous materials handled by this business is contained solely in a consumer product, <br /> packaged for direct distribution to, and use by, the general public. <br /> ❑B. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical <br /> gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes X[No Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. ❑Yes C' 4o Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> 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 <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. <br /> I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge. <br /> Owner or Authorized Agent <br /> x ✓ 40(r1� ,+ ;-0,7"11 Date: 12 z S// <br /> Print N me <br /> X M C C Title:�t��� <br /> Signature <br />