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SAN JEnvironmental Health Department COU N -i- Y HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and /or address in San Joaquin County . Business Name : Telephone : 17TBusiness Site Address : � G� c Mailing Address ( if different from above ) : Business Owner(s ) Name : I A, IfNsl lm6cg IL JJ ftfAAAZphone : Business Owner Address : L4 n I E- 13 Nature of Business : Fire District : Q1 . ❑ Yes 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 klo Does your business generate , treat , or store a hazardous waste in any quantity? ( used oil , used antifreeze , waste solvent , etc . ) IF your q �� swer is " No " to boeh . ques } 'sons in Q1 , please print, sign , and date the bottom of this form and re: turil Liu the address above . Q2 . ❑ Yes 10 Does your business handle a hazardous material , ora 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 . ❑ B . This business operates a farm for purposes of cultivating the soil , raising or harvesting an agricultural or horticultural commodity . Q3 . n Yes No Does your business handle an Acutely Hazardous Material ? See definition on page 2 . Q4 . ❑ Yeslo 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 : �� ,' �' ' ) c'. `� fir, r D i � V) �1 E r1 VSignature : "�t ' c �-� �. ! - c/ e Title : CITY ,�l �c 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 1 www . sjcehd . com