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P. . ? 200254 <br /> sAN.,;JOAQuiN Environmental Wealth Department <br /> .._c 0 u NT Y-......._. <br /> Greotness draws hare. <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form Is required for each business name and/or address in San Joaquin County. <br /> a <br /> Business Name: o,w i N t cl s e,s, +!LC-Telephone: -LF)q '-1 y 14 2. 1)____ - <br /> Business Site Address: =�' �, � � v.)-6 cLkj• Off. Cc,, <br /> Mailing Address(if different from above): P(S B e'C' q 3Y k 5L 9 <br /> Business Owner(s)Name: C.(vet` RI V'-_ _,Telephone: <br /> Business Owner Address: <br /> Nature of Business: V<: ITcnt �-f ECL C k <br /> 0 1G. Ct PFe7Dlstrlct: <br /> Q1, Wes n No Does your business handle a hazardous material in any quantity at any one time In the year? <br /> See the dofinitlon of hazardous material on page 2 of this form. <br /> W Yes ❑No Does your business generate,treat,or store a hazardous waste In anyguantlty?(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 shove. <br /> Q2. o Yes o 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 /> n 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 /> n B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. o_Y-es n-No _Does your-businos s-handle-an-Acutely-Hazardous-Material?—See-definition-on-page-2. — <br /> Q4. n Yes I n No Is your business within 1,000 feet of the outer boundary of a school?(Grades K-12) <br /> have read the Information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br /> Code(IISC), 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 ro s,caepa.ca,c o to submit your hazardous materials Information. <br /> Owner or Authorized Agent: <br /> Print Name: ~b�' e-P t--% U, , X­� \ N t Date: <br /> L <br /> Signature: Title: <br /> 0 1 <br /> 1868 E. Hazelton Avenu© I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />