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J an. 10. 2020. AIV, OH Q U I N Environmental Health Uep'artment ---COUNTY** HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form IS required for each business name and/or address in San Joaquin County, Business Name:_ffigj �- r �Telephone' Business Site Address: Mailing Address(if different from above), D) Business Owner(8) Name: Telephone, Business Owner Address. TO Rm na(? ?gg 7aO Nature of Business: G G34TJD Fire District: 01- Yes o No Does your business handle a hazardous material in any auantlty at any one fine In the year? See the definition of hazardous material on page 2 of this form- o Yes a No Does your business generate,treat,or store a hazardous waste In any quantity?(used oll,used antifreeze,waste solvent,etc.) If your answer Is"No"to both questions in 01,please print,sign,and date the bottom of this form and return to the address above. Q2. Yes o No Does your business handle a hazardous material,or a 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? It"Yes",how long have you handled these materials at your business? 11 )3 If"Yes",cNck any of the following conditions that apply to your buslnoss: rj 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. 0 B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an agrIcuftural or horticultural commodity. Q3. 0 Yes rt No Does your business handle an Acutely Hazardous Material? See definition on page 2. 04. 0 Yes Po Is your buslwss 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 most be met prior to Issuance of a Certificate of occupancy or beginning of operations. I declare under the penalty of perjurythal the informatlon provided on this disclosure survey Is true and accurate to the best of my knowiedge, if you answered"Yes"to Question 2,please goonllna to cers.0lem,ca.a2y to submit your hmzardous materials Information. Owner or Authorized Agent: Print Name: Date. ry Signature, Title: 1)V