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1 <br /> f <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: Fire Wings <br /> Business Owner(s) <br /> Name: Billy Phong Telephone: 9165458888 <br /> Business <br /> Address: 6625 Pacific Ave, Stockton CA <br /> Mailing Address(if different from <br /> above): 9105 Bruceville Rd 6A, Elk Grove CA 95758 <br /> Nature of <br /> Business: Fast Casual Restaurant- Wings Fire District: <br /> Q1. ❑Yes fNo 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. ❑Yes fallo Does your business handle a hazardous material,or a mixture 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 /> ❑A. 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 /> ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes f9No Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. ❑Yes f9No 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 /> 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: 3�30�2021 <br /> X Billy Phong Date: <br /> Print Name manager <br /> X `C\ Title: g <br /> Sig natdN <br />