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EB / 07/ 2017/TUE 07 , 51 AIS COMMUNITY DEVELOPMEN FAX No . 12099378893 P1001 / 001 <br /> '.' 6, 1 .1 <br /> dde RECEIVED <br /> ' AN J0dvd1kQUf .N COUNTY <br /> • �y::< E NN 'Vml (� Iv i�lf � i t '1 ',1 :� ,i,. -i J.'.. E� A.., tl �l4 X.�' 4 �r I`!, 11'a A i ;°Y A r.. . <br /> es ,, FEB Q 2017 <br /> 1888 East !di-lazelton Avenue , Stockton , CA 95 05-6232 <br /> y Telephone (2.09 ) 466%d-3-420. Fax 1249 ) 46401 ,38 ENVIRONMENTALH <br /> 4`r.>+nN, jcat�cl :corr PERMIT/SERVICES H <br /> HAZARDOUS MATEMALS WSCLOSURE, SURVEY <br /> A separato survey form is required for each business nam6 and/dr add?68s in San Joaquin County. <br /> G � � - <br /> Business Nam . � � 7 al4phane: ,L�. S � <br /> Bualti'es9 Site Ad'dkegs: �{ G �L( V`Q .f" k- t) ( A <br /> Ma1IIn9. Addre158;' (lf dlff>;rront froM dabove). ^ � <br /> B.usiaoss '0w0or(s) tuemo: _ C N� " y t� ^� Telephone; <br /> ugiciHsB Owne�.Add> ea r ` oot eA 1 ,5" <br /> i <br /> l�iatue Of B' Wslrfetig; ot: __�___ <br /> Q1 . r, Yes iddd boas your iiw'slrt®.as tidndla . .Pfazrardrfu;a material In eby . Quarifty. at, any one time* in. the. <br /> yoail Seri the ddfi Rion of hatzardouarnatorlai on, page 2 of this form , <br /> a yes; zw [7.oes yourpti4slrips8moon© rate , treat, bi- sfofa a hEkirdbus waste fn any . quentitv7 (used oil, <br /> u'sed 'dn4lfr®eye, wa�tt� s�o(von#; tile;) . <br /> li yaura►YSW ,ice?'Na"' t'o .t oth q(IetEtl4Yts do t41 ,. piQaae {7rititr4igti , andandreturn' :to fhe atidis*e' alSove, <br /> t v Ye 8, ,a {Jo Daer, your• %$I iese hayidIQ a' hazardous :rmt�Jtl�lr o'r a rriii? tur® contalning t� hazardous <br /> rnaterial .An a; quantity. equal, to or oreater than �6 gallone) '5t?0 pounds, ol- 200 cubic feet at <br /> Alf ::oriotimettn . thsyear't <br /> if' <br /> ;'NYi3s", how long. hove 'yotA handtocJ #ha�e: rtiaterfr�is. 8r'yR�r;' WWI,0S;57 <br /> If`''Yes",t .check .any-Df 'the follouving oonditions that apply tonyour business' <br /> n A• The .hazsr nee niaton6is handied .w this bosindess are contained solely. In a consumer <br /> prc5:du t p6ak� ed fdY dirty &g.tdibutian. to and uW by thy+ ganorai p'ublio. <br /> o Bt This- businesed operates a farm' for :purpa�e of .ciliflV8 9 the ebil , ri ising or harvesting an <br /> agekulturWbi hoitiaultura( coritrriodity. <br /> Q 1 a Ye , hlnDbes •your, busin''ess�. h.an <br /> ' d16 ab Acu#ely' Hazardous Material,? 84e •dehniflon on page 2. <br /> 04.. o Yes o N6. la your busine" se withln 1. 1000 feet of tho ou.tar b6t4pdairy' of a 'sdhool.? (Grades K"1 �) <br /> I have( read tho inforMation on this form and understand my tequirements under Chapter-O.JS of the . Galifornia Heafth • and Safety <br /> Code. (HSC): 1 ainde stancithat l I own a falciliity or .pxop611y that• 1'a used .by tenants, It 1s My. respom1bility to notlfy khe. tenants of <br /> we idddifuti snts whibh,5 must. be tnet prior to Issuance of a. .Gertffibate of Oocupd niwy or beginning .of operations. I declare under <br /> 'th'e pgftlty Af penury that Ethe Inform;Ocin provided. on thts disiygsurd survey is . twi. and accurate to the bast of my knowledge . <br /> Ifyod -ansWorbd "Yes" to Questloli 2 , pJiaase go Qnline to 0ers .4n1er)0,ca .g_ov to subrriit your'hdazardous materials. inforrrfation. <br /> Owrior or: Authorized Agent. <br /> Print NiRm % N PC &MI � ' • Data: � / � �7 <br /> Signature: <br /> EHQ 19wb2 1 MMSP6URVEY <br /> Revlacd` d/25/16 <br /> Received Time Feb , 7 . 2017 6141AM No . 0786 <br />