SU0013958 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN Environmental Health Department "' !.• COUNTY Greatness grows here . HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and /or address in San Joaquin County . Id ,,tt�� Business Name : `'Jr k i 12rJJQjVhA Telephone : go ') , F5 � Business Site Address : so N � i' 40 1 ro in ei d � , d_� to e k iravoN c _ Mailing Address ( if different from above ) : A a + r Business Owner( s ) Name : i� , j ,, I/ Telephone : Business Owner Address : �?, v L � 1T S ✓� P u� , )�� a �- r r Nature of Business: ! � �' Fire District : �� rlCa . , HQ /'q Q1 . ❑ Yes KNo Does your business handle a hazardous material in any quantity at any one time in the year? See the definition of hazardous material on page 2 of this form . ❑ Yes VNo Does your business generate , treat , or store a hazardous waste in any quantity ? ( used oil , used antifreeze , waste solvent , etc . ) 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 . Q2 . ❑ Yes © No Does your business handle a hazardous material , or a mixture containing a hazardous material , in a quantity equal to or greater than 55 gallons , 500 pounds , or 200 cubic feet at any one time in the year? If "Yes " , how long have you handled these materials at your business ? If "Yes check any of the following conditions that apply to your business : ❑ A . The hazardous materials handled by this business are contained solely in a consumer product packaged for direct distribution to and use by the general public . ❑ B . This business operates a farm for purposes of cultivating the soil , raising or harvesting an agricultural or horticultural commodity . Q3 . ❑ Yes V No Does your business handle an Acutely Hazardous Material ? See definition on page 2 . Q4 . ❑ Yes ❑ No Is your business within 1 , 000 feet of the outer boundary of a school ? ( Grades K- 12 ) have read the information on this form and understand my requirements under Chapter 6 . 95 of the California Health and Safety 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 requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations . I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge . If you answered "Yes " to Question 2 , please go online to cers . calepa . ca . ov to submit your hazardous materials information . Owner or Authorized Agent : Print Name : " lj (�� Date : LI Z 2� S Signature : Title : J & VAI 001 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 1 www . sjcehd . com