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/22/2017/MON <br />09:26 AM <br />■: y -.. <br />G <br />is •.y <br />e <br />c .. <br />s <br />FAX No. <br />?.001/001 <br />SAN JOAQUIN COUNTY 17 v- 0 2 9 2�0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone (209) 468-3420 Fax (209) 464-0138 <br />www.sjcehd.com <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: Safewayff1769 „ , Telephone: 209-461-5555 <br />Business Site Address: 2808 Country Club Blvd., Stockton, CA <br />Mailing Address (if different from above): <br />Business Owner(s) Name: Nicholas Sgeno (Trustee) Telephone: <br />Business Owner Address: 1371 Oakland BlydL Suite 200, Walnut Creek. CA 94596 <br />Nature of Business: Grocery <br />Store Fire District: <br />Qt, o Yes o <br />Does your business handle a hazardous material in any quantity at any one time in the <br />year? See the definition of hazardous material on page 2 of this form. <br />:1Yes <br />r <br />Does your business generate, treat, or store a hazardous waste in aril duentity? (used oil, <br />used antifreeze, waste solvent, etc.) <br />If your answer is "No" to both <br />questions in 01, please print, sign, and date the bottom of this form and return to the address above. <br />02. o Yes o <br />Does your business handle a hazardous material, or a mixture containing a hazardous <br />material, In a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at <br />any one time in the year? <br />If "Yes", how long have you handled these materials at your business? <br />If "Yes", check any of the following conditions that apply to your business: <br />o A. The hazardous materials handled by this business are contained solely in a consumer <br />product packaged for direct distribution to and use by the general public. <br />o B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. o Yes No Does your business handle an Acutely Hazardous Material? See definition on page 2 <br />Q4, o Yes "o Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12) <br />have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br />Code (HSC). I understand that H I own a facility or property that is used by tenants, it is my responsibility to notify the tenants of <br />the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under <br />the 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 mrs.caleoa.ca.gov to submit your hazardous materials information. <br />Owner or Authorized Agent <br />Print Name: Debi <br />^Plaisionce 407-643-2347 DebiP(}ac-p.cotn Date: �s � olp-cq <br />Signature, 1 ^ ) Title: Permitting Coordinator <br />CEIVED <br />MAY 12 2017 <br />EHD 19-02 1 HM9P SURVEY <br />ReNsed 6/25116 ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Received Time May.22. 2017 9:19AM No. 1545 <br />