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Telephone:(2_C c-6 915 -335-2. <br />Qii).2-10 <br />tiv-t c tch 572-(k, <br />(2..ccl) qtr.-335-) Telephone: <br />0 -2105//C <br /> Title: / " pe raiz.; v- <br />Owner or Authorized Agent: <br />Print Name: <br />Date: <br />RECEIVED <br />FEB 1 7 2016 <br />San Joaquin County <br />Environmental Health Department <br />'1868 E Hazelton Avenue <br />Stockton, California 95205 <br />DIRECETNY,-I.°'NMENTAL HEA <br />- " . LTH Donna 'VICES <br />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, REHS <br />Rodney Estrada, REHS <br />Adrienne Ellsaesser, REHS <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209)468-3433 <br /> <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: Pre lily) 71re ci TQL.-i <br />Business Site Address: ic.) .-Stijk: 06'0 <br />Mailing Address (if different from above): /6 ?- <br />Business Owner(s) Name: je etc . ? <br />Lccl , <br />chk e I <br />::14'7 t L <br />Business Owner Address: <br />Nature of Business: A L.LivA to h vf repkir 4 'Tv <br /> <br />Fire District: <br />Ql. C_64' '' Y es a No Does your business handle a hazardous material in any quantity at any one time in the <br />year? See the definition of hazardous material on page 2 of this form. <br /> <br />i/'es a No Does your business generate, treat, or store a hazardous wasteirl ar_jLit ? (used oil, <br />used antifreeze, waste solvent, etc.) <br />If your answer is "No" to both questions in Ql, please print, sign, and date the bottom of this form and return to the address above. <br />02. o Yes No <br />Does your business handle a hazardous material, or a mixture containing a hazardous <br />material, in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at <br />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 apply to your business: <br />A. The hazardous materials handled by this business are contained solely in a consumer <br />product packaged for direct distribution to and use by the general public. <br />B. <br />This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />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 (HSC). I understand that if I own a facility or property that is used by tenants, 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. I <br />declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of <br />my knowledge. <br />Q3. o Yes ?la° <br />04. Ypq 1;b-No