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SAN JOAQUIN Environmental Health Department <br /> ' COUNTY <br /> ,, ,. . Greatness grows here. <br /> HAZAR�OLJS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form Is raquiratl for each business name antl/or atltlress in San Joaquin Counly. <br /> Business Names: TrDck One Telephone: <br /> Buslneas site Atltlreas: 30022 Highway 33, Tracy CA 95304 <br /> Mailing Adtlrass(if tlifferent from above): 14�51 Newport AVB. Ste. 203, Tustin CA 92780 <br /> Business Owners)Names: CA33 LLC Telephone: (3'12)9'12-'1833 <br /> Business owner Aadresa: X4951 Newport Ava. Sta. 203, Tustin CA 92780 <br /> Natures of Buslnass: Travel Stop Fke District Tracy FD <br /> Q2. m Yes o No Doas your business nantlla a hazertlous material In env a antlty at any one rima In the year? <br /> sae the definition of hazardous materiel on page 2 of[hla form. <br /> m Vas o No Doea your business generate,treat,or store a hazertlous waste In env cuantity?(used oll,used <br /> antifreeze,waste solvent.etc.) <br /> If yow answer le"Nq"to both quaatlona In p1,please prinq algn,antl data fha boHom M tbls farm antl rafum to the edtlraaa above. <br /> Q2. m Yes o No Doas your business hantlle a hazertlous material,or a mixture containing a hazardous malarial, <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 handlatl rheas materials et your business? N/A <br /> If"Yes",check any of[ha following conditions[hat apply to your business: <br /> m A. Tha hazertlous matarlals hantlled by this business era contalnatl solely in a consumer product <br /> packagatl for tlirect distribution to and use by the general public. <br /> o B. This buslnasa operates a farm for purposes of cultiveiing fha soil, raising or harvesting an <br /> agrlcghgral or horiicq¢grel commgmty. <br /> Q3. o Yes m No Doas your buslnasa hantlla an Acutely Hazardous Material? Sae tleFnition on page 2. <br /> Q4. o Yas m No Is your business within 2.000 feat of[he outer boundary of a school?(6retla&K-22) <br /> I have read[ha Information on[his form and understand my requirements untler Chaplar 6.95 of[ha Callfomia Haelth antl Safety <br /> Cotle(HSC). I untlars[antl that if I own a facility or property that is used by[enanta,it is my responsibility[o notify[ha tenants of the <br /> requirements which must ba met prior to Issuance of a Certificate of Occupancy or beginning of uperaHons. I tladara untler the <br /> penalty of pe Jury that the Information provitletl qn Ihis tlisclosure survey Is true and accurate to the best of my knowlatlga. <br /> If you answered"Yas"to Question 2,please go online to rers caleca v[o submit your hazertlous matarlals information. <br /> Owner or Authorizatl Agana <br /> Print Name: Gpulb-aI_h_a'-r Saini Deta: -- --- <br /> 5lgnawre:�W�r^*`r^� ��hl Tiue: President <br /> 2B6B E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0'138 I www.sjcehd.com <br />