Laserfiche WebLink
SAN ; <br /> 8 k� | r� 0 7 � <br /> N Environment <br /> �� U�� �� r�m � <br /> ��11NJ! V | �Lk ��| � � ^ ^ �~����UrK�k��06���L . ^ x����x+^x ����C2��" ^"^"����~ <br /> '` ' ----C ] JNTY---' <br /> :�:eo 2ra�� 6c/e <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Asepoote survey form isrequired for each business name and/or address|nSan Joaquin County. <br /> ` . /� <br /> Business Name: Telephone: <br /> Business Site Address: <br /> ��YD <br /> M�i�Add���dBom�fmmab�o'. � <br /> Business Owno4o) Name: Telephone <br /> Business Owner Address: <br /> Nature ofBusiness: Fire District: <br /> / <br /> Q1. [3 Yes m�No Does your business handle uhazardous material blany quantitVutany one time inthe year? <br /> See the definition ofhazardous material onpage 2ofthis form. <br /> oYon dVIN Does your business generate,treat,orstore uhazardous waste in any quantity?(used oil,used <br /> antifreeze,waste solvent, o&nj <br /> nyour answer in^mo^uoboth questions ino1.please print,sign,and date the bottom ovthis form and return mthe address above. <br /> U2. oYox Ao 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 /> inthe year? <br /> |f^Yes''. how long have you handled these materials a1your business? <br /> If"Yes",check any of the following conditions that apply to your business: <br /> o& The hazardous materials handled by this business are contained solely in a consumer product <br /> packaged for direct distribution 0oand use bythe general public. <br /> oO. This business operates a fonn for purposes of cultivating the ooU, raising or harvesting an <br /> agricultural orhorticultural commodity. <br /> U3. oYen o Does your business handle anAcutely Hazardous Material? See definition onpage 2. <br /> O4. oYeo k//No Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12) <br /> | have read the information on this form and understand my requirements under Chapter 6.85 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. | 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 /> |fyou answered^Yoo''toQuestion 2' please Ooonline<o tosubmit your hazardous materials information. <br /> Owner orAuthorized Agent: <br /> Print N : / ^' <br /> Signature: d|o: v 14,0 ti <br />