Laserfiche WebLink
:� <br /> = �`��; SAN,4,.l0AQlJIN �rtvar®n�e�,ga� Hea�t� ®�p�t-xn,ertt <br /> ��.ci}��•.•� Gceq to ass g'ro ws Rere. <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is requlretl for each business name and/or address in San Joaquin County. cc / <br /> Business Name: TOP ��.MA-N —T7Z L1Gls[t Nny SNG Telephone: Z� �72f J u Qp <br /> 6usmess seta Address: ,�_�� G �u � )-7h �T —r2 A� _ Q'# �+ S 3 0� <br /> Mailing Address(if different from above): ��Tv�C R3 FOJ�- <br /> Business Ownar(s)Nama: N 7 IT s/ Y�] Telephone: ',Z O Q• 32) 5 t{'�a <br /> ausiness owner Address: '-+`�'-� t-t) t t��" —T � A' �/ G 1h d1 .S 3��'/ <br /> Nature of Business: �_T ��ug-tG�� - Fire District: —TsC./"1 <br /> 01. o Yea pNo Ooas your business handle a hazardous material Ina an4N at any one time In the year? <br /> Sea the tleflnition of hazardous material on page 2 of this forth. <br /> o Yas >9 No Ooas your business generate,treat,or store a M1ezardous waste'n envguanfity?(used oil,used <br /> antifreeze,waste-solvent,etc.) <br /> IT your answer Ia'•No"[e beth quastlona In Q'1,please print,sign,ane data the bottom of thla form antl return W the atldmsa above. <br /> Q2. v Yas o No Goes your business handle a hazartlous malarial,or a ml#ure containing a hazartlous material, <br /> in a quantity equal to or greater than 55 gallons,500 pounds,or 200 cubic feat at any one Yime <br /> m the year? <br /> IY'Yes",how long M1ava you handled these materials at your business? <br /> If"Vas",check any of the following conditions Met apply to your business: <br /> v A. Tha.hazardous mafarials handled by MIs business are contained solely in a wnsumar product <br /> packa9atl for direct distribution to and use by Me generel public. <br /> v 6. This businasa operates a iartn for purposes of cultivating the soil, reusing or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. v Yas v No Ooes your business handle an Acu[aly Hazardous Material? Sae definition on page 2. <br /> 04. o Vas v No Is your business within '1.000 feat of the outer boundary of a school?(Greens K-12) <br /> i have read the Information on this form and undarstentl my requirements under Chapter 6.95 of the California Health antl Safety <br /> Code(HSC). 1 understand[hat if I own a facility or property that fs used by tenants,i[is my responsibility to notify iha tenants of the <br /> requirements which muss ba mat prior to Issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the infortnetion provided on tM1ia disclosure survey is true and accurate to the best of my knowledge. <br /> If you answaratl"Yes"to Question 2, please go online to care.calaoa.ce.gov to submit your hazardous materials information. <br /> Owner or Authorized AganY <br /> Print Name: /t')f�f�\�T' Si�'�t� �� Data: O Z )o Z�Z�©2O <br /> ' Signature: (�w-?.7��" �N� Title: '1�-{"�-��\^T`Dl Pt-v)P7/ <br /> �o `J <br /> 'IR6R F Ha>altnn Aveniia I Stnnktnn. California 95205 I T 209 468-3420 I F 209 464-0'138 I www.sicehtl.com <br />