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SAN JOAQUIN <br />COUNTY <br />Gr�ctr,ess grows here <br />Environmental Health Department <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: M eco A Liv & P &Z�t.\ TQ \i Telephone: s;� % e) (y 7 / <br />Business Site Address: 1 � Z U .S • %au.�r�fLc.1 .� �` • ������i U,�� � c�5 �{j <br />Mailing Address (if different from above) <br />Business Owner Address://�� 3 7c) A�4E VA El Xy 5414TU!✓. -� �_C? <br />✓ <br />Nature of Business: Jo. &t LILY Fire District: �' V t9 S�d C{�--�D•� <br />Q1. y�Yes ❑ 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 Z. of this form. <br />❑ Yes tV 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 />02. ❑ Yes %><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? <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 />Ze 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 />03. ❑ Yes yNo Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. ❑ Yes pa~No 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.gov to submit your hazardous materials information. <br />Owner or Authorized Agent: <br />Print Name: <br />S <br />Date: S /3 / 22. <br />ignature: <br />r—T <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sjcehd.com <br />