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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 Kasey Foley, REHS Linda Turkatte, REHS Rodney Estrada, REHS Adrienne Ellsaesser, REHS <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: Trajen Flight Support LP dba Atlantic Aviation Telephone: 209-98 2-1622 <br />Business Site Address: 6364 Lin dbergh St., Stockton, CA 95206 <br />Mailing Address (if different from above): ___________________________ _ <br />Business Owner(s) Name: Joseph LeBel Telephone: _5_0_3_.6_8_4_.0_4_4_3 _____ _ <br />Business owner Address: 6364 Lindber gh St., Stockton, CA 95206 <br />Nature of Business: -�Fi�x=e�d �B�a�s�e�d�O-=--p-e �ra�t�o�r _________ Fire District: Montezuma <br />Q1. O(Yes □ No <br />t(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 />Q2. <br />Q3. <br />Q4. <br />!¾Yes □ 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 )Q No <br />□Yes }II 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:� ��7..-· Date: <br />1 <br />Revised 11/07112