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RE�E�VE� <br />San Joaquin County <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />DIRECTOR <br />Donna Heran, REHS <br />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda.Turkatte, REHS <br />JE <br />Rocfd�c�Estra <br />Adrre�ne AIs <br />rte..,.. _, . <br />V 1 <br />MAY 0 7 2015 <br />:R HAZARDOUS MATERIALS DISCLOSURE SURVEY �][��j� /� <br />sutbZOg <br />rv�uform is required for each business name and/or address in San Joaqu_:[, ��P0NMENTA1_ <br />R�1gs �ne: Telephone: otoo10 1 <br />r� Business Site_A�ddres . `-r Fr'o rl'h e (--)(--+r„in rA C)C--)'2 1 '=, <br />(if different from above): <br />Akl Business Owner(s) Name: Telephoner q44 02 <br />oS__ Business Owner Address: <br />`j36Nature of Business: c50 Y �% l 1n Fire District: <br />Q1. AYes ❑ No 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 />txYes ❑ No C waste in any quantity? (used oil, <br />If your answer is "No” to both question: ;j Dn . _ and return to the address above. <br />�..0�-Sl-� � . <br />Q2. ❑ Yes KNo mixture containing a hazardous <br />�S 500 pounds, or 200 cubic feet at <br />aiM+, �� �� '7 +o - 201 2vL <br />If <br />SIV 0 C.�-Cv h1 <br />If <br />-"S ❑A. TI <br />pr <br />❑ B. Tt <br />it business? <br />Q, your business: <br />;ontained solely in a consumer <br />leneral public. <br />he soil, raising or harvesting an <br />Q3. _._. _. ❑..Yes_ . )(No -D( `� ? -See definition on page 2: <br />Q4. ❑Yes No Is \ , N� (' R-0 Q a school? (Grades K-12) <br />I have read the information on this fc a5 of the California Health and <br />Safety Code (HSC). I understand that it 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 or Authorized Agent: <br />Print Name: Tenl,�D-e l.N� F Date: <br />Signature: VLX�a " ' Title <br />Revised 11/07112 <br />J4 1,31 <br />5 212s <br />