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San Joaquin County <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sjgov.orglehd <br />Phone: (209) 468.3420 <br />Fax: (209) 468-3433 <br />DIRECTOR <br />Donna Horan, REHS <br />PROGRAM COORDINATORS <br />Robert McCollon, RENS <br />Jeff Carrussoo, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkana, REHS <br />Rodney Estrada, REHS <br />Adrienne Ellsaesser, REHS <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name andfor address In San Joaquin County. <br />Business Name: hro, 1 �)yL Telephone: j 0 (p - 1 q )A.{-_ <br />Business Site Address: I���I�I N, I�IGIiI �tl6f J�ItJJ <br />Mailing Address (if different from above): <br />Business Owner(s) Name: Lodi. (ii I Telephone: _t�0 `3L[ - Igig <br />Business Owner Address: I(IgSi 1 o i e -A <br />Nature of Business: ! ' ili�dy�__. ___ Fire District: _ <br />Q1. )(Yes o No Does your business handle a hazardous material In any cuan0ty at any one time In the <br />year? See the definition of hazardous materiel on page 2 of this form. <br />)(Yes $No Does your business generate, treat, or store a hazardous waste.jn env auanliW (used all, <br />F. used antifreeze, wasto solvent, etc.) <br />If your answer Is "No" to both questions In Q1, please print, sign,'and date the bottom of this form and return to the address above, <br />Q2, o Yes o No Does your business handle a hazardous material, or a mixturecontaining a hazardous <br />materiel, In a quantity equal to or greater than 55 gallons, 600 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 />c 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 />u B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. u Yes o No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />\4, o Yes n No Is your business within 1,000 feet of One outer boundary of a school? (Grades K-12) <br />I have read the Information on this form and understand my requirements under Chapter 6.95 of the California Health and <br />Safety Code (HSG), 1 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 requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I <br />declare under the penalty of perjury that the Information provided on this disclosure survey Is true and accurate to the best of <br />my knowledge. <br />Owner orAuthorized Agent: <br />Print Name: I,&.tyir whroLe, _Data: 10.12-91IV <br />Signahire: �t-uR.J �'�.� , �/tl��rci{�, ____rale: r7)h�i'1,4 ✓ _ _ <br />