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"`�AR/15/2017/WED <br />1 ryggq '� <br />r` <br />01:52 PM COMMUNITY DEVELOPMEN <br />FAX No,12099378893 <br />P. 001/001 <br />SAN JOAQUIN COUNTY RECEI Y E <br />ENVIRONMENTAL. HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 952056232 A 15 2(!1 <br />Telephone(209)468-3420 Fax(209)464-0138 <br />vvww.sjcehd.00m &0AINlit <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: Walmart Store #1554 Telephone: (209) 473-2796 <br />Business sits Address: 3223 E Hammer Lane, Stockton, CA 96212 <br />Mailing Address (if different from above): <br />Business Owners) Name: Walmart Stores, Inc. Telephone: 1479) 204-2702 <br />Business Owner Address: 2001 SE 10th Street, Bentonville, AR 72716 <br />Nature of Business: Retail Fire District Stockton <br />Q1, X Yes o No Does your business handle a hazardous material In_goy quantity at any one time In the <br />year? See the definition of hazardous material on page 2 of this form. <br />xyss ❑ No Does your business genarats, treat, or store a hazardous waste jp_gpy ousntlry? (used oil, <br />used antifreeze, waste solvent, etc.) <br />If your answer Is "No" to both questions In 01, please print, sign, and date the bottom of this form end return to the address above. <br />Q2. g Yee o No 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, 60D 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? 2004 <br />If "Ye®, check any of the following condltlons that apply to your business: <br />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 />q B. Thls business operates a farm for purposes of cultivating the sell, raising or harvesting an <br />agricultural or hortloultural commodity. <br />Q3. o Yes X No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. n Yes X No Is your business within 1,000 feet of the 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 Safety <br />Code (HSC). I understand that K 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 Cert'fiicste of Occupancy or beginning of operations. I declare under <br />the penalty of perjury that the Information provided on this dlaclusure survey is true and accurate to the best of my knowledge. <br />If you answered "Yes" to Question 2, please go online to perS.gaIena.ca.gov to submit your hazardous materlais information. <br />Owner or A'uthorizedl�l A/�glee1n�t: <br />Print Name: "Y'jIry/v(\+ Date; <br />Signature:J _ l r1�J1 <br />(� 1 <br />/ Title= <br />EHD 19-02 <br />Rs,,red 6125/18 <br />MAR 15 2017 <br />C Ornmr 1r) t, n--,1o11)pment <br />Received Time Mar 15. 20118,1 46,6 ei/oduciingWslon <br />HMBPSJRVEY <br />