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San Joaquin County Environmental Health Department 1868 E Hazelton Avenue Stockton, California 95205 Website: www.sigow.org/ehd Phone: (209) 468-3420 Fax: (209)468-3433 c DIRECTOR Donna Heran, REHS PROGRAM COORDINATORS Robert McCleson, REHS Jeff Cama , RENS, RDI Kasey Foley, REHS LIn0a Turkane, REHS Rodney Estrada, REHS Adrienne Etsaessef, REHS HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and/or address in San Joaquin County. Business Name: _IN Business Site Address: Mailing Address (if different from above). Business Owner(s) Name:..[�'`n1 K,J Business Owner Address: _t Nature of Telephone: i - 014Z A 9%Z01 �_4aa_ A24Z Fire District: 15fDCk f0!3 01. If Yes ❑ No Does your business handle a hazardous material in any DuantiN at any one time in the // year? See the definition of hazardous material on page 2 of this form. Q Yes 0Mo Does your business generate, beat, or store a hazardous waste in any buantiM (used oil, used antifreeze, waste solvent, etc.) If your armr is No- to both quesdons M Q1, planes prim, sign, and data tat bottom of this form and ratum to the address above. 02 es ❑ No Does your business handle a hazardous material, or a mixture containing a hazardous material, in a quantity equal to or greater then 55 gallons, 50O pounds, or 200 cubic feet at any one time in the year? r7,, If 'Yes', how long have you handled these materials at your business? 90ob If 'Yes*, check any of the following conditions that apply to your business: ❑ 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. ❑ B. This business operates a fans for purposes of cultivating the soil, raising or harvesting an / agricultural or horticultural commodity. 03. 00 611 a No Does your business handle an Acutely Hazardous Materiel? See definition on page 2. 04. Was o No Is yourbusiness within 1,000 feet of the outer boundary of s school? (Grades K•12) &U, 174Mc i.«d . I have read the information on this form and understand my requirements under Chapter 6.95 of the Cokfomis 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 must be met prior to issuance of a CeNfrAte 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 Print N Signature: a�� nArM1i Authorized Agent: ame: ZI Date: L7 10 JZoi4 r [/ WX& 1bVL . Title_