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RECEIVED <br /> COUNTY OF SAN JOAQUIN <br /> Environmental Health Department FE6 1 7 201? <br /> 1868 E Hazelton Avenue <br /> Stockton , California 95205 ENVIROWENI- Ltt rtfTH <br /> Telephone (209) 468 -3420 PEl41MtTrqERWX:$ <br /> FAX (209) 466-3433 <br /> Website : www,sjgov . org/ehd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> pSease read the %%4zme. Ede betcse aomveet N tk�',s suv o" Sossrr , A separate suvvw• #os ead) b sS) SS <br /> name and/or address in San Joaquin County is required . <br /> Business ,4 �+ <br /> Name : tm)aw GPeet4ltos G01110;�dwwy lff' Ajct <br /> Business Owner (s) <br /> Name : ✓ iker f + �� S• �� Telephone : <br /> Business <br /> Address : 101k . 7J#&&�fA1 , •4 � �/ C�� j it,�T r� 75 � /"fr` <br /> Mailing Address (if different from � nn r J <br /> above) : a y yl/ �. COAD i C-� � �N i AI <br /> Nature of <br /> Business : �?f--� Fire District : � ct,5,? <br /> Q1 . *es ❑ No Does your business handl a hazardous material in any quantity at any one 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 , se(es ❑ 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 ? •sti cns. <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 /> 03 . ❑ Yes * o Does your business handle an acutely hazardous material ? See definition on reverse side of this <br /> form . <br /> 04 . ❑ Yes Gi o 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 pr Authori d Agent : <br /> X G ✓ G L.4f:: Date : <br /> X r Title : .4t�0&1044ciY 'CIa-r c <br /> nature <br /> F/AppUc ionsFc rms&Handouts/PlanningApplicalions/Businoss License (Revised 02 .24- 15) <br /> Page 4 of 6 <br />