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4 T/ 18/ 2016 /TUE07 , 11 AM COMMUNITY DEVELOPMEN FAX No , 12099378893 P0001 / 001
<br /> RECEIVED
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<br /> OCT 18 2016 00
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<br /> ENVIRONMENTAL HEALTH
<br /> SaR A TtR� ►1l my f
<br /> s� nvironmental Health Department D
<br /> IRFCTOR
<br /> iDonna He an, RF,H6
<br /> 1868 E Hazelton Avenutr PROGRAM
<br /> �As
<br /> Stockton , California 96255 Robert McClellan, REHS
<br /> Cartuosco, {l
<br /> Jeff FtDi
<br /> Wobsite : WWW,sj£tpv,drg/ehd Linda Turkatte, REH5
<br /> Phonal, (209) 468w3420 Rodn®y Estrada , REHS (f
<br /> Fame (209) 468-3433 Adrienne Elrsdusser, REH8
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<br /> HAZARDOUS MATERIALS DISCLOS URO SURVEY
<br /> A separate survey form is required for each business name and/or address in San Joaquin County,
<br /> Business Name; La Telephone:
<br /> Business Site Andress: U U ISX3 _
<br /> Mailing Address (if different from above): "
<br /> Business Owner(s) Narne : , . /t,r_J 6. PrOX.4AI Telephone:
<br /> Business Owner Address, �
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<br /> Nature of Business: , fj6io 1JL7 1 CJ4^YAi .+e... t=ires District: p/1
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<br /> Q1 , XYes n No Dues , your business handle a hazardous materialin. any, q��tlty( at any one time in the {
<br /> year? See the definition of hazardous material on page 2 of this form,
<br /> Ayes ONO Does your business. generate, treat, or store a hazardous waste in any quantity? (used oil, {
<br /> used antifreeze, waste solvent, etc.) j
<br /> if your answer Is "No" to both questions is R1 , ptaase print, sign, and date the bottom of this forth and return to the address above.
<br /> 02. XYes a No Does your business handle a hazardous tnatartal, or a mixture contolning a hazardous
<br /> malarial, in a quantity equal to or greater than 55 .gallons, 500 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? yeer6
<br /> if ^Yes°, check any of the following conditions that apply to your business:
<br /> i3A, The hazardous inaterials handled by this business are contained solely In a consumer
<br /> product packaged for direot distribution to and use by the general pubiio,
<br /> 0 B. This business operates a farm for purposes of cultivating the soil, relsing or harvesting on
<br /> agricultural or horticuitural `commodity.
<br /> Q3. o Yes )j No Does your business handle an Acutely Hazardous Material? See definition on page 2,
<br /> Q4, o Yes )( No Is your business within 1 ,000 feet of the outer boundary of a sohool? (Grades K--12)
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<br /> I have road the information on this form and understand my reguirementa under Chapter 6,95 of the California Health and !
<br /> safety Code (HSC), 1 understand that if I own a facility or property that is used by tenants, it Is my responsibility to notify tha E
<br /> tenants of the requirements which inust be met prior to issuance of a Certificate of Oocupancy or beginning of operations , i
<br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of j
<br /> my knowledge. I
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<br /> Owner or authorized Agent : I
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<br /> Print Nettie' _ 14l►ti . i9 'r % Bate: ' 15
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<br /> Signature , Title;
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<br /> Rwa� n�ln� '
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