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B � � aio0i5� <br /> COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> Telephone(209)468-3420 <br /> FAX(209)468-3433 <br /> Website:www.sjgov.org/ehd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business <br /> name and/or address in San Joaquin County is required. <br /> Business <br /> Name: LA FAVORITA <br /> Business Owner(s) <br /> Name: Karina Cerna-Valdez and Vanessa COrteZ Telephone: 8125 5 EL DORADO ST <br /> Business <br /> Address: 8125 S EL DORADO ST <br /> Mailing Address(if different from <br /> above): <br /> Nature of <br /> Business: Deli and Service Station Fire District: French Camp McKinley <br /> Q1. Was ❑No Does your business handle 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. DYes ❑No Does your business handle a hazardous material, or a mbdure 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? <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> OA. 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 /> 11 C. This business operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. DYes ®No Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> 04. ❑Yes ONo 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. 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 or Authorized Agent. -� <br /> X K n em venae= Date: M�") r u Z <br /> X ! t a Title:President <br /> i na ' <br />