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RECEIVED <br />FEB 1 7 2016 <br />San Joaquin County <br />Environmental Health Department <br />1868 E HazeIton Avenue <br />Stockton, California 95205 <br />D Donna <br />I RE CETN•lic_1" • A ". r4 <br />ERV1C S <br />mENTAL HEEALTH <br />PROGRAM COORDINATORS <br />Robert McClellan, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, REHS <br />Rodney Estrada, REHS <br />Adrienne Ellsaesser, REHS <br />Webs ite: www.sjg ov.o rg/eh d <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 />Pre 2114:) 7; re Telephone:C-2-C 9! 5-- 3352 <br />16, m e Avt. SIocJl ( 4 crs-itk <br />,0 -1; 'L <br />fetes a No Does your business generate, treat, or store a hazardous waste in ar__.iLgLIantIty? (used oil, <br />used 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 />02. o Yes <br /> <br />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 />Q3. o Yes ?ado Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />04. a Yes ‘FoNo 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 />Owner or Authorized Agent <br />Print Name: <br />ti: /2-d‘eut /ift Date: 0 / <br /> Title: am.e, <br />Business Site Address: jC) <br />Mailing Address (if different from above): <br />Business Owner(s) Name: ji; <br />Business Owner Address: <br />Nature of Business: A /()iA o Vf rtth,r 4 Tot.ickty Fire District: <br />Ql. Cd?Yes a No <br />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 />Business Name: <br />-sibcicivv? Lcd , cfri Q4-2A0 <br />(Icri)q15--335-) Telephone: