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i °aU cG� SAN JOAQUINEnvironmental Health Department COUNTY Q90 Greatness grows here . PA Z 30001 0 HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and /or address in San Joaquin County . Business Name : Telephone : Business Site Address : 4215 , 4223 , & 4245 E MAIN STREET Mailing Address ( if different from above ) : 3833 N ARATA ROAD Business Owner(s ) Name : RAFAEL ZEPEDA Telephone : 209 - 279 - 4203 Business Owner Address : 3833 N ARATA ROAD Nature of Business : RETAIL / FAST FOOD Fire District : EASTSIDE ( STOCKTON ) Q1 . ❑ Yes o No 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 . ❑ Yes o No 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 Q1 , please print, sign , and date the bottom of this form and return to the address above . Q2 . ❑ Yes ■ No Does your business handle a hazardous material , or a mixture containing a hazardous material , W n 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 . ❑ B . This business operates a farm for purposes of cultivating the soil , raising or harvesting an agricultural or horticultural commodity . Q3 . ❑ Yes o No Does your business handle an Acutely Hazardous Material ? See definition on page 2 . Q4 . ❑ Yes o No Is your business within 1 , 000 feet of the outer boundary of a school ? ( Grades 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 own a facility or property that is used by tenants , it is my responsibility to notify the tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations . I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge . If you answered "Yes " to Question 2 , please go online to cers . calepa . ca . gov to submit your hazardous materials information . Owner or Authorized Agent : Print Name : Rafael Zepeda Date : OCT 6 2022 Signature : A Title : V NtAd (! 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468- 3420 1 F 209 4641,,, 0138 1 www , sjcehd . com