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, <br /> COUNTY OF SAN JOAQUIN 'BL- Q200aa7 <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 AUG 2 6 212 <br /> Telephone(209)468-3420 <br /> FAX(209)468-3433 <br /> Website:www.sjgov.org/ehd DI 11\10 Nil \ I <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business <br /> name and/or address in San Joaquin County is required. <br /> Business ,f <br /> Name: GTS 2 21-e5 Yon--7-P Cop,-rj <br /> Business Owner(s) (�' <br /> Name: 1 64 YI f7G loo(eh C 1 c' )Business <br /> Telephone: / qq S3g3 <br /> Address: 3g2 oo .S' C�'Ji�,��f'J'a, �1 Tl-ae- .l l07- 953'7.7 <br /> Mailing Address (if different from r7P I , r f W <br /> above): !� 5 Y l7°�tJ rt ISI. <br /> Nature of <br /> Y <br /> Business: 3 r,/( I r Fire District: 4 <br /> Q1. ❑Yes M/O Does your busin ss handle s hazardous material in any quantity at any one time in the year? See the <br /> /definition of hazardous material on the back of this form. If your answer is No,'.go to Question 4. <br /> Q2. DYes IVU Does your business handle a hazardous material,or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at 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 applies to your business. <br /> DA. The hazardous materials handled by this business is contained solely in a consumer product, <br /> packaged for direct distribution to, and use by,the general public. <br /> DB. This business is a health care facility(doctor, dentist,veterinary,etc.)and uses only medical <br /> gases. <br /> DC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. []Yesallo Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. []Yes QNo Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code. I understand that if I own a facility or property that is used by tenants, that 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. <br /> I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge. <br /> Owner qr Authorize Agent: -Z <br /> X s r f4C' <br /> DC2f0 Date: <br /> Print Nam <br /> X Title: - <br /> Sign <br />