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SAN _ JOAQUIN Environmental Health Department <br />COUNTY <br />Greatness cricws here. <br />02i00093 <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />t.. .f¢T,43 t,L c <br />Business Name:^ E Telephone: Aanqi 3G2-0[Gwi <br />Business Site Address: 1177 Lk_-) l 1 7441A.Qe, C <br />Mailing Address(if different from above): <br />Business Owner(s) Name:_E-C.,'*yzrmc-o_S L C Telephone: At-5 —7r.0— l s'55L <br />Business Owner Address: 1777 W i rr+,4 ST . =gag., G17 t 3i0y <br />r <br />Nature of Business: Fire District: <br />Q1. Yes o Does your business handle a hazardous material in any quantity at any one time in the year? <br />Ir See the definition of hazardous material on page 2 of this form. <br />Yes •; I"0 Does your business generate, treat,or store a hazardous waste in any quantity? (used oil,used <br />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. Yes No Does your business handle a hazardous material,or a mixture containing a hazardous material, <br />in a quantity equal to or greater than 55 gallons, 500 pounds,or 200 cubic feet at any one time <br />in the year? <br />If"Yes", how long have you handled these materials at your business? <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 product <br />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 />Q3. Yes No Does your business handle an Acutely Hazardous Material? See definition on page 2, <br />Q4. Yes No 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 Safety <br />Code(HSC). I understand that if I own a facility or property that is used by tenants, it is my responsibility to notify the tenants of the <br />requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br />penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br />If you answered"Yes"to Question 2, please go online to cers.calepa.ca.gov to submit your hazardous materials information. <br />Owner or Authorized Agent: <br />r <br />Print Name:—E. L ti i.m fLS ----C— Date: <br />Signature: Title: M_ 4*,P4t 1,,-)4 tl <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com