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�rEC/16/2016/FRI 11:30 AM COMMUNITY DEVELOPMEN FAX No,12099378893 P,001/001 ■ 4 COUNTY ENVIRONMENTAL HErALTH DEPARTMENTRECEIVED 1868 Fast Hazelton Avenue, Stockton, CA 95205-6232 • Telephone (209) 468-3420 Fax (209) 464-0138 DEC 16 2016 www.sjcehd.com ENVIRONMENTAL HEALTH PERMIT/SERVICES HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and/or address In San Joaquin County, Business Name: Safewav #1769 Telephone; 209-461-5555 Business Site Address: 2808 Country Club Blvd., Stockton, CA Mailing Address (if different from above); Business Owner(s) Name: Nicholas Sbeno (Trustee) Telephone; Business Owner Address; 1371 Oakland Blvd, Suite 200, Walnut Creck CA 94596 Nature of Business; Grocery Store Fire District: 01_ ❑ Yes ?40 Does your business handle a hazardous material In any quantity at any one time in the year? See the deflnitlon of hazardous material on page 2 of this form. El Yes Flo Does your business generate, treat, or store a hazardous waste in any quantity? (used oil, 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 A 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', how long have you handled these materials at your business? 11 "Yes', check any of the following conditions that apply to your business: 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. n l3, This business operates a farm for purposes of cultivating the soil, raising or harvesting an agricultural or horticultural commodity, Q3, ❑ Yes /0100 Does your business handle an Acutely Hazardous Material? See definition on page 2. Q4_ C1 Yes i 40 Is your business within 1,000 feet of the outer boundary of a school? (Grades K•12) 1 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 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. If you answered "Yes" to Question 2, please go online to cers,calepa.oa,goy to submit your hazardous materials Information. Owner or Authorized Agent; Print Name: _ Debi Plaisance 407-643-2347 DebiP@c-p.com Date SignatU16 : Tltle: EHD 10-02 Reviaad 8/25/18 Received Time Dec.16, 2016 10:21AM No -0514 Permitting Coordinator HMBP SURVEY