Laserfiche WebLink
•✓.-----oUTTv-·---­/o�·•" "'•• .. c:,- <br />/":>.•' ··.O <br />!,:' 1,··i :-< . . <br /># • . . . --�-.-� '•--....._F� <br />San Joaquin County <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />DIRECTOR Donna Heran, REHS <br />PROGRAM COORDINATORS Robert McClellan, REHS Jeff Carruesco, REHS, ROI l<asey Foley, REHS Linda Turkalle, REHS Rodney Estrada, REHS Adrienne Ellsaesser, REHS <br />HAZARDOUS MATERIALS ISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: Trajen Fli ght Support LP db a Atlantic Avia ti on Telephone: 209-982-1622 <br />Business Site A ddress: 6364 L indbergh St., Stockton, CA 95206 <br />Mailing Address (if different from above): ____________________________ _ <br />Business Owner(s) Name: Joseph LeB el Telephone: _5_0 _3_.6_8_4_.0_4_4_3 _____ _ <br />Business owner Address: 6364 Lindbergh St., Stockton, CA 95206 <br />Nature of Business: -�Fi�x�e�d�B�a�s�e �d�O-+p�e�r�a�to�r _________ Fire District: Montezuma <br />01.O(Yes c1 No <br />�Yes □No <br />Does your business handle a hazardous material in any quantity at any one time in the <br />year? See the definition of hazardous material on page 2 of this form. <br />Does your business generate, treat, or store a hazardous waste in any quantity? (used oil, <br />used antifreeze, waste solvent, etc.) <br />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. <br />02. <br />03. <br />04. <br />t¾Yes □No Does your business handle a hazardous material, or a mixture containing a hazardous <br />material, 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? 07.15.2006 <br />If "Yes", check any of the following conditions that apply to your business: <br />□A.The hazardous materials handled by this business are contained solely in a consumer <br />product packaged for direct distribution to and use by the general public. <br />□B.This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />□Yes )(} No <br />□Yes � No <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12) <br />I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br />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 <br />tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy 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 <br />my knowledge. <br />Owner or Authorized Agent: <br />Print Name $ Lb-'b'L_..-. ·Date: <br />Signature � Title: <br />1 <br />Revised 11107112