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PA 2 30 Q P� 5 o <br /> SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> Greatness grows here . <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and /or address in San Joaquin County . <br /> Business Name : George ' s County Cafe Telephone : 209 - 727 - 5745 <br /> Business Site Address : 18700 CA- 88 , Lockeford , CA- 95237 <br /> Mailing Address ( if different from above ) : <br /> Count Cafe Foods Inc 559 - 301 - 3700 <br /> Business Owner( s ) Name : y Telephone : <br /> Business Owner Address : 18700 CA- 88 , LOckeford , CA- 95237 <br /> Nature of Business : Restaurant Fire District : Mokelumne Rural Fire <br /> Q1 . o Yes ❑ No Does your business handle a hazardous material in any quantity at any one time in the year? <br /> See the definition of hazardous material on page 2 of this form . <br /> o Yes ❑ No Does your business generate , treat , or store a hazardous waste in any quantity? ( used oil , used <br /> antifreeze , waste solvent , etc . ) <br /> 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 . <br /> Q2 . ❑ Yes o No Does your business handle a hazardous material , or a mixture containing a hazardous material , <br /> I <br /> n a quantity equal to or greater than 55 gallons , 500 pounds , or 200 cubic feet at any one time <br /> I <br /> n the year? <br /> If "Yes " , how long have you handled these materials at your business ? <br /> if "Yes " , check any of the following conditions that apply to your business : <br /> ❑ A . The hazardous materials handled by this business are contained solely in a consumer product <br /> packaged for direct distribution to and use by the general public . <br /> ❑ B . This business operates a farm for purposes of cultivating the soil , raising or harvesting an <br /> agricultural or horticultural commodity . <br /> Q3 . ❑ Yes o No Does your business handle an Acutely Hazardous Material ? See definition on page 2 . <br /> Q4 . ❑ Yes o No Is your business within 1 , 000 feet of the outer boundary of a school ? ( Grades K- 12 ) <br /> I have read the information on this form and understand my requirements under Chapter 6 . 95 of the California Health and Safety <br /> 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 <br /> requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations . I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge . <br /> If you answered "Yes " to Question 2 , please go online to cers . calepa . ca . gov to submit your hazardous materials information . <br /> Owner or Authorized Agent : <br /> Print Name : County my Cafe Foods Inc Date : 11 /06/2023 <br /> Signature : Title : CEO <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 T 209 468- 3420 1 F 209 464 - 0138 1 www . sjcehd . com <br />