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SAN JOAQ'_! IN Environmental Health Department <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A Warato survey form - refit.red for each b =r>fMs name andbr addMSS in Sa- Jo=quin County <br /> tiusnxss Name Lockeford materials Telephone: 209-329-1412 <br /> euss)WA She Morews 18303 N H W Y 88 Lockeford Ca 95237 <br /> Mailing Address(rf diffararr.'rom above): PO BOX 980 Lockeford Ca 95237 <br /> otsness Ownor(s)Nam Jesse Meza Toephono 209-329-1412 <br /> NA iwiss Owner Addra": 17875 N Hillside Dr <br /> Nature a AuSriM, landscape material sales Fire DOM Mokelumne <br /> 01 -Yes - Ne L)oes your owinew nancm a na.7aroous mate+at in any ouantay at any one time in r>e year? <br /> See the definition of hazardous material on page 2 of T- = form <br /> - Y" =No Dons your busme"generate,treat or store..hazardous waste in any aJaMity?(ised oil uses <br /> anufreoce.waste solvent etc) <br /> h your answer Is"No-to Data gwetfons In Q1,please print sign and dale Vie bottom of this form and rstum to Me addrses above. <br /> Q2 _YCS No DOOS you -,uSn0% and 0 a hazardouS matortal or a m Aurc cont: 'ung a hazardo_z mato al, <br /> in a quanirty ritual in or greater than 55 galloris, 500 pouna5 or 200 cubic tee at any one lime <br /> in the yew*7 <br /> If 'Yrs' a%long'lave you handled thwsw materids M yrxn busirmys? <br /> P'Yen' Check any of bine td Ow A COndrtrOAS that&Wv to You bkxwvSS <br /> A Tho hazardous ma_:°: :handled by this buwass are contained so Gly in a oortsumer product <br /> packagiM to-punct drsmOut on to and use by ftte general pulAc. <br /> H I his Omness owates a farm for purposes of ptJttryatrng the nor. ran" or hanfCni ung an <br /> agricultural or horticuttura onmmodity <br /> 03 Yes NO foes you business hand a an Ap/te y Hazardot.- Mate9al7 See definition on page 2 <br /> (A. Yes No Is your business wrtrrin 1 000 feet of the outs boundary of a achool?(Gnmwx K-12 <br /> I have read the iniarmation on this form and understand my requiremerns undo Chapter 6 96 of the Califon a Health and Safety <br /> CWe(HSQ I tn0er510nCl Thal 1110")a faCs ty or property that is us;d tyy tenants rt -. my responsibi rty io nouly the tenants of the <br /> requirements Nn mi>_st be met pno- to tanaw a of a Certificate ot Occupancy or beginning of operations 1 declare under the <br /> peri-fty of per..iy that the information provided on Ih: disCOS ure"very is tru_ar'd accurate to the bow of my knowlodge. <br /> yo-.arvwad'Yes'to Ouf3slion 2 please go cry no to :XLZV=fdU,:: to submit your hazardous matonals ntormatron. <br /> owner or Attthoi--zed Agent G <br /> r <br /> PrirsName � V►S 4 `�'�-GA- Hale ��2D�� Z <br /> A gnature: .r o / Title W�TII <br /> 1 r�4 E i-}.cr: C,11 4 0:-t le I StCi k:dn. Caftfriae 952'" I T P-9 4fj8-34I F 9-1-7A-03' ... sjr:ho C <br />