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<br /> If your answer Is"W'to trothclue tons in Q1,please print,sign,and date the bottom of this form and return to the address above.
<br /> Q2, RjYes a No Does your business handle a hazardous material, or a mixture containing a.hazardous
<br /> material,in a quantify equal to or greater than 55 gallons,500 pounds,or 200 cubic feet at
<br /> any one lime 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 /> r3 A. Tata hazardous materials handled by this business arts contained solely in a consumer
<br /> product packaged for direct distribution to and use by the general public.
<br /> a 8, This.business operates a farm for purposes of cultivating the soil, raising or harvesting an
<br /> agricultural or horticultural commcdiiy,
<br /> Q3. a Yes ✓INo + Does your business handle an Acutely Hazardous Material? See definition on page 2.
<br /> Q4, o Yes RjNo is your business within 1,000 feet of the outer boundary of a school?(Grades 14.12)
<br /> I have read the information on thl form and understand my requirements under Chapter 6.95 of the California Health and Safety
<br /> Code(HSC). I understand that H i owry a facility or property that is used by tenants,it is my responsibility to notify the tenants of
<br /> the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under
<br /> the penalty of perjury that the inf`rmation provided on this disclosure survey is true and accurate to the best of my knowledge.
<br /> Owner or Authorized Agent. y{
<br /> Print Name: -'h Date, t
<br /> f - -
<br /> Signature Ti#le .
<br /> ita..a Emma
<br /> SanJoaquin County Environmental Health Department
<br /> AZARDQUS MATERIALS PROGRAM
<br /> This survey form is intended to.itdentify businesses which need to comply with.the hazardous materials emergency planning and
<br /> reporting requirements of the C fomis Health and Safety Code(HSC)Chapter 6.95. This Chapter requires businesses which
<br /> handle hazardous materials to pi'pare emergency pians fortbeir employees to use to an emergency. Businesses must submit
<br /> a copy of this plan,along with ark annual Inventory of their hazardous materials,to public safety agencies for use in protecting
<br /> emergency responders and the i eneral public. In San Joaquin County,the Environmental Health Department(EHD)has been
<br /> authorized to administer this proiiram as the Cerafied Unified Program Agency or Ct1PA. Should you have any questions about .
<br /> the CUPA program or this form, lease contact EHD at(2D9)458-3420, 1
<br /> Please consider the following gu delines when completing the questions on page 1:
<br /> Question 1:
<br /> The (HSC) section 25601(p) de rtes a"Hazardous Material" as any material that, because of its quantity,concentration, or
<br /> physical or chemical characterL,character' tics,:poses a significant present or potential hazard to human health and safety or to the
<br /> environment if released into the i vorkplace or the environment "Hazardous Materials"include but are not limited to,hazardous
<br /> substances,hazardous waste,acid any material that a handler or the administering agency has a reasonable basis for believing
<br /> that it would be injurious to the health and safety of persons or harmful to the environment if released into the workplace or the
<br /> environment. This includes, bL is not limited to, fuels, petroleum products, paints, propane, oxygen, ammonia, chlorine,
<br /> pesticides, fertilizers, and used x1, If a business generates any amount of hazardous waste they must enroll in the EHO
<br /> Hazardous Waste Generator Pr gram. Answer"Yes'if you use a material that meets the definition above in any quantity at
<br /> least once in the year.. If you are unsure,contact the EHO at(209)468-3420 for assistance. if you answer"No'and at a later
<br /> dateour business or a tenant o
<br /> i y , ji your property,begins handling.hazardous materials,you must inform the EHD within 30 days.., j
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