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P <�, �� -� 1 . Pg2000- <br /> � � 1 <br /> n� tal Healt epartmen <br /> COUNTY <br /> {' 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. <br /> Business Name: vn Ckv LA0U 't006 Telephone: Q)09� 5�4-oza <br /> Business Site Address: l` 'a U okN C\vU mV :S? CVtb1 CA QO IA <br /> Mailing Address(if different from above)�:A_r_ -] C� �CSC(1 RC� !`� v2�b�f1 Y,1 C ccIS30 <br /> Business Owner(s)Name: PC,& V b�c\oXTg-\CL& �J 1 Telephone: AGO(Aj S3�1-O�a-7 <br /> Business Owner Address,.:,_"_ a-1o7 V lessor Rd I afVef-\oa h, CA 15367 <br /> Nature of Business: &(XIG 1�T(XUe( iCkj 0d) LW Fire District: <br /> j, I <br /> Q1. ❑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 2 of this form. <br /> ❑Yes Xf 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 01,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2. ❑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 /> ❑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 X 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.00v to submit your hazardous materials information. <br /> Owner or Authorized Agent: \.�\ i <br /> Print Name: 60 MOrCI m G ,t Date: 1—')-� <br /> J ' q <br /> Signature: I Title: Owy�of <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />