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PA230026U <br /> SAN JQAOUIN Environmental Health Department <br /> --COUNTY— <br /> Greutrress grows here. <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name andlor address in San Joaquin County, <br /> Business Name: Telephone: <br /> Pleasant Valley Farms, INC DBA Jenkins Poultry Farms 209-886-1000 <br /> --- ---.... <br /> Business site Address: 30636 E. Carter Road Farmington, CA 95230 <br /> Mailing Address(if different from above): <br /> Richard Jenkins 209-652-2278 <br /> Business Owner(s)Narne: Telephone: <br /> Business Owner Address: 30636 E. Carter Road Farmington, CA 95230 <br /> Nature of Business: Poultry Farm Fire District: Farmington <br /> Q1, Q Yes n No Coes your business handle a hazardous material in�4y quantity at any one time In the year? <br /> See the definition of hazardous material on page 2 of this form. <br /> „Yes a No Does your business generate,treat,or store a hazardous waste i rp an uan i 7(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. o Yes I,No Does your business handle a.hazardous material,ora mixture containing a hazardous material, <br /> in a quantity equal to or greater than 55 gallons,50a pounds,or 200 cubic feet at any one time <br /> in the year? <br /> If"Yes",how long have you handled these materials at your business? 2012 <br /> If'Yes", check any of the following conddlons that apply to your business: <br /> n 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 /> m B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. L Yes m No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> 44, Yes m No Is your business within 1,000 feet of the outer boundary of a school?(Grades K-17.) <br /> I have read the information on this form and understand my requirements under Chapter 6.95 of the Callfornis 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 brrginning 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 ryrs,ealeaa.ca.aov to submit your hazardous materials Information. <br /> Owner or Authorized Agent: <br /> Pant Name: Richard Jenkins Date: ��- ALL- 3 <br /> Signature: 1, l _ Title- CRO <br /> 1868 B. Hazelton Avenue i Stockton, California 95205 1 T 209 466.3420 1 F 209 464-0138 1 www.sjcehd.com <br />