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SAN 1OAQUIN a <br /> °mac° Environmental Health Department <br /> COUNTY <br /> c4 ; W Greatness grows here , <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County, L <br /> Business Name : �� C hef foods LLC Telephone : 207 — 2 �l — ✓ ��� _ <br /> Business Site Address : MA l p /� �/� J • ;to 640e alz <br /> Mailing Address ( if different from above ) : <br /> Business Owner(s ) Name : TPA J�j COS1r �+ Telephone: 7 , O Cl ( S (o 7 � e � <br /> Business Owner Address : LlZ ?, ( C• ptA-(L i POS 4 IZ D s%bGkyo IJ CA 5S�41 S <br /> Nature of Business : C) o c) F✓! n/U F A, uru R fki G- Fire District: �' coc t4n> til C , 7 <br /> Q1 . res ❑ No Does your business handle a hazardous material in any quantity at any one time in the year? <br /> See the definition of hazardous material on page 2 of this form . <br /> Xes o No 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 . W es ❑ 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? / Q <br /> If 'Yes" , how long have you handled these materials at your business? �/� C of <br /> i <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 . ❑ Yesrvlo 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 .goy to submit your hazardous materials information . <br /> Owner or Authorized Agent: <br /> Print Name : Ca i C , � MEff Date : <br /> Signature : Title : <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www . sjcehd . com <br />