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p►artment SAN _JOAQUIN Environmental health Re -- COUNTY- -- .. Greoz rtSS HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and/or address in San Joaquin County. Ir Business Name: t` ) (Are p (,� - -17 h Tele hone: Business Site Address: 1011 A)- RIZaA �1Al , AV(41- kkk.- Mailing Address (if different from above): Business Owner4 q Telephone; s) Name: -� �`- t t�� Business Owner Address: M�7 Mv4,6 ChV,15'- Nature of Business: �C. - L-i i t -JAAC, Fire District: 0mi l " Q1. o Yes VN o Does your business handle a hazardous material in any quantity at any one time in the year? See the definition of hazardous material on page 2 of this form. o Yes A0 Does your business generate,treat, or store a hazardous waste in any quantity? (used oil, used antifreeze, waste solvent, etc.) If your answer is"No"to both questions In 01, please print, sign, cmd date the bottom of this form and return to the address above. 4' Q2. ❑ Yes d No Does your business handle a hazardous material, or a mixture containing a hazardous material, in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time in the year? If"Yes", how long have you handled these materials at your business? If"Yes", check any of the following conditions that apply to your business: ❑ A. The hazardous materials handled by this business are contained solely in a consumer product packaged for direct distribution to and use by the general public. o B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an agricultural or horticultural commodity. 61 Q3. o Yes � No Does your business handle an Acutely Hazardous Material? Secs definition are page 2. Q4. o Yes o No Is your business within 1,000 feet of tie outer boundary of a school? (G�3-des K-12) I have read the Information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety Code (HSC). I understand that if I oven a facility or property that Is used by tenants, it is my responsibility to notify the tenants of the M!'!st_ hp- met nrin fo ccraar�re of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury that the Inf6rmat'ron provided can this disclosure sLiRiey is tree and aerate to the best of my kno—iMcdge. please go online to �rs.ca[G a.ca.ga4�to submit your hazardous materials information. If you answered "Yes" to Question 2, Owner or Authorized Agent: Print Marne: i� ir'� €? ,, pate: tf 11 - ' Signature: Title: 1868 E. F-1 !zelton Avenue ►, Stockton, California 95205 T 209 468-34.20 F 209 464-0138 vPAr ✓.sjcehd.corn