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COUNTY OF SAN JOAQUIN OFFICE OF EMERGENCY SERVICES 2101 E. Earhart Avenue, Suite 300 STOCKTON, CA 95202 TELEPHONE.(209) 953-6200 lamb ,ic. / -:5 © READ VIM 31 2014 ETMRONMENTAL HEALTH HAZARDOUS MATERIALS DISCLOSURE SURVEY PERMIT/SERVICES Please read the information on the reverse side before completing this survey form. A separate survey for each business name and/or address in San Joaquin County is required. Business Name: TRACXPIL SsPPII.a 601.AP0.44 Telephone: Business Site Address: 3(00 5. Gi%✓ eoyek L V- LZID1 4A 06MP Mailing Address (if different from above): Business Owner(s) Name: Tthe Tap .�i> P" 411 Telephone:, (1pk6I A4-0. ��q5 Business Owner Address: 2-M Pb4.1 -I I TSI".P` ct— �P � �� b_OU tT^+ '3�2•� Nature offBBusiness: SWA4 4swPMEMI T, 17atre�11JAMF.A �1: �SCre District: 6gmi or- LorA Ql. f L es ❑No Does your business handle a hazardous material in any quantity at any one time in the year? See the N', definition of hazardous material oil the back of this form. If your answer is "No", go to Question 4. Q2. ❑Yes []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? If "Yes", [low long have you handled these materials at your business? If "Yes", check any of the following conditions that applies to your business? -*A. The hazardous materials handled by this business is 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. ❑Yes f�W0 Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form. Q4. [:]Yes(((5I�I��\o 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. I understand that if I own a facility or property that is used by tenants, that 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. Owner or Authorized Ageent:.r�,, Print Name X t LAA4 VAZtFXXJ nle Signature (Rev 8/08)