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e <br />ENN117,40NMENTAL <br />HEALTH DEPARTMENT <br />San Joaquin County <br />Environmental Health Department <br />1668 E t iazelton Avenue <br />Stockton, California 95205 <br />Website: w,ryw.sjgov.orglehr-1 <br />Phone: (209) 4138-3420 <br />Fax: (209) 468-3433 <br />DIRECTOR <br />Donna Heran, REHS <br />PROGRAM COORDINATORS <br />RODert McClellon, REHS <br />Jeff Carrr,esco, REHS. RGI <br />Kasey Foley, REHS <br />Linda Turkatte, REHS <br />Rodney Fstrada, REHS <br />Adrienne Ellsaesser, REHS <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey torr Is roqu red for each business name :and/or address in Sari Joaquin County. <br />Business Name -6\1 <br />Business Site Address:— <br />Mailing Address (if different from above) - <br />Business Owner(s) Name_QQC1 <br />bove)3usinessOwner(s)Nam©QQ(jdE�l ... Telaf.hone:1��},��___..ZQ--__ <br />Business Owner Address <br />Nature of Business:1L�1,[l1,_ ____ Fire District: <br />Yes No Does yOUr busmess handle 9 hazardous material in anv auantitr at any one time in the <br />year? Sec- the definition of hazardous niaterial on page 2 of this form. <br />r: Yes No Doe% your business generate, treat, or store a hazardous waste in any gr.iar�tity? (used oil, <br />used antifreeze. waste solvent etc ) <br />If your answer is "No" to both questlorm in 01, please print, sign, and date the boltum of this turns and return to the address above. <br />C12. Yes No Does your business hsndlr. a hazardous material, or a mixture containing a hazardous <br />material. in a quantity equal to or greater than 55 gaiions, 500 pounds, or 200 cubic feet at <br />any one time in the year? <br />If "Yes", now long have you handled these materials at your business? <br />If "fes", check any of the following conditions trat appiy to your business: <br />A. The hazardous materials handled by this business are contained solely in a consumer <br />product packaged for direct distrnoution to and use by the general public. <br />B. This business operates a farm for purposes of cultivating the soil, raising o. harvesting an <br />agricultural or horticultural commodity. <br />03. Yes oNo Does your business handle an //cutely Hazardous Material? See definition on page 2. <br />04. Yes jr, No a your business within 1,0Q0 teet of the cuter ooundary of a school? (Grades K-12) <br />I have read the information on this form ano understand my requirerneriL under Chapter 6.95 of the California Health and <br />Safety Code (H5C) I understand that if I own a facility or property that is used by tenants, it is my responsibility to notify the <br />tenants of the requlrernents which must be mat prior to issuance of a Certificate of Occupancy or beginning of operations. I <br />declare under the penalty of perjury that the information providers on this disclosure survey is true and accurate to the best of <br />my knowledge. <br />Owner or Authorized Agent <br />Print Name:—S11ldi_SGI— ----- — _-----Date: -- — <br />Signature// fle <br />Rwiwtl � tl07H i <br />