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Environmental Health Department <br /> SAN JOAQUIN <br /> — C?U i�1 Y---- <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY 1 ` <br /> A separate survey form is required for each business name andior aodiesa <br /> Tru by Hilton - Lodi - _J__,Setephone: - <br /> Business Name: - - _ - ------- <br /> 6125 WBanner Street, Lodi, CA 9524 N C� C1620- <br /> Business Site Address. - - - <br /> Mailing Address(if different from above): n,•,n_! r s, (7l 9 <br /> �. —T phone: ,.2�--4 <br /> 3 <br /> Business owner(s)Name: <br /> Business O►vnet Address: Woodbridge Rural District <br /> Nature of Business: <br /> Hotel Fire District: <br /> nt at any one time in the year? <br /> Does your business handle a hazardous materiel2 of this f��Y <br /> Qt n Yes v No See the definition of hazardous material on pag ,an used oil,used <br /> ®No Does your business generate.treat,or store a hi v hazardous waste in anatenUt ?i i <br /> Yes antifreeze,waste solvent,etc.) <br /> rn to the address aim®• <br /> if your answer is"Mo"to Moth questions in Qt,please Print.Sign,and date the bottom of this form and rata <br /> No Does your business hardie aan u Ballo aterns,508 pounds,or 200 cubic feetat any one taining a hazardous e�me <br /> Q2 Yes In a quantity equal to or greater <br /> in the year? r business? ----- <br /> If"Yes',how long have you handled these materials at you <br /> It'`fes",check any of the following conditions that apply to your business: <br /> The hazardous materials harxited by this busrnes9 are contained solely in a consumer product <br /> o A. general public. <br /> packaged for direct distribution to and use by the g rnoor harvesting an <br /> r B. This business operates a farm nforrippurposes of cultivating the soil, rt aising <br /> agricuitural or horticultural co <br /> Yes n No Does your business handle an Acutely Hazardous Material? See definit;on on page 2 <br /> Q3 a of a school?tGrades K-12) <br /> Qq ❑Yes W No <br /> Is your business Within 1,000 teet of the outer boundary <br /> rstand myrequirements under Chapter 8.95 of gibeitrl California <br /> notify Fthe tenalth an s ofl©e <br /> on form and tnat is used by tenants,it is my respo I declare under the <br /> 1 have read the u de stand that ifiI own a facility OT proper'y t n or beginning of Operations. knoarledge <br /> Code(HSC)• r to issuance of a Certificate of OccuPa cY <br /> requirements which mthe be met prix y <br /> Wally of perjury information provided on this disclosure serve is true and accurate azthe <br /> d us� rruatenais information. <br /> Pe a�v to submit yo <br /> if you answered"Yes"to Question 2.please go online to ers.caierS <br /> owner or Authorized Agent: <br /> pate: <br /> Print Name:�-�-J+v�- - - _- <br /> 1 J Title: <br /> Signature: <br /> 1866 F. Blaze <br /> Ilan Avenue I Stockton,Califomia 95205', T 249 468"3420 I F 209 <br /> 464-0138 1 %Vww sjcehd.cotn <br />