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- SQNS��QQU � N Environmental Health Department <br /> COUNTY—- <br /> NAZAR�OUS MATERIALS OISCLOSU RE SURVEY <br /> A separate survey form is required for each businaas name and/or address in San Joaquin County. <br /> 6uainaaa Nana, Valley Pacific Petroleum Services, Inc Telephone: 0209) 715-3295 <br /> easiness seta Addrasa: 3550 S. Hwy 99, Stockton, CA 95215 <br /> Mailing Aaaress(If dlmarent rrgm abgya>: 152 Frank West Circle, Stockton, CA 95206 <br /> easinasa owner<a)Names: Valley Pacific Petroleum Services, Inc ralaphona: (209) 948-9412 <br /> easiness owner Aaaress: 152 Frank Wast Circle, Stockton, CA 95206 <br /> Nafera of ausinesa: Commercial Fuel/Lubricants Fire DiatNcr Montezuma <br /> Ot. s Yes o No Does your business nendle a hazardous materiel in env c antlN ai any one time In iha year? <br /> See the definition of hazardous material on page 2 of this form. <br /> r Yas o No Doan your businaas 9anareta,treat,or store a hazardous waste in env ouantity?(used oil.used <br /> an[Ifreaza,waste solvent,etc.) <br /> IP your answer la•'No"to both quaatlonv In p1,plaaaa print,alpn,an,1 data Na boHom of tbla form and ratum to<ba adrlraea abeva. <br /> 02. a Yas o No Doea your businaas handle a hazardous matadal,or a miMure containing a hazardous material, <br /> In a quantity equal to or greater than 55 gallons,500 pounds,or 200 cubic feet a[any one lima <br /> In ma year? <br /> If"Yas",how long have you handled these materials a[your business4 �� Years <br /> If"Yas",check any of[ha following conditions[hat apply to your businaas: <br /> o A. The hazardous materials handled by this business are containetl solely In a consumer product <br /> peckagetl for direct tlistributlon to and use by the general public. <br /> v B. TM1is businasa operates a farm for purposes of cul[Ivating [ha soil, raising or harvesting an <br /> agdculturel or horticulture?commodity. <br /> 03, o Yes u No Does your business handle an Acutely Hazardous Mater1a11 See tlagniilon on page 2. <br /> 04. o Yas s Nc Is your businaas within 1,000 feat of the outer boundary of a scM1ool?(Gradae K-12) <br /> I have read the Informaflon on fhls form and understand my raqulramaMa under Chapter 6.95 of iha Callfomla Health and Safely <br /> Coda(HSC). I untlarefand that if I own a faclllry or property that is used by<ananis,it is my responsibility[o notlfy the tenants of the <br /> requirements which muss ba mat prior to Issuance of a Cartiflca[e of Occupancy or beginning of operetions. 1 tleclare under the <br /> penalty of perjury that Iha information provided on this disclosure survey is 4ue and accure[a to tba best of my knowledge. <br /> If you answered'Yes"[q Quasflon 2. please go online[o cars.calaoa ov fo submit your hazardous metal'lals IMormation. <br /> Owner or AuthoNzed Agent: <br /> arint Names: Michael Arnold Data: 1/24/24 <br /> slgnatare: �Q Tltla: Project Safety Manager <br /> 1868 E. Hazelton Avenues I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 www.sjcehd.com <br />