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RECEIVEC <br /> OCT 05 2015 <br /> M <br /> ENTAL San Joaquin County <br /> DIRECTOR <br /> sonniiir Environmental Health Department Donna Heran,REHS <br /> 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> Stockton, California 95205 Robert McClellon,REHS <br /> Jeff Carruesco,REHS,RDI <br /> Kasey Foley,REHS <br /> Website: www.sjgov.org/ehd Linda Turkatte,REHS <br /> Phone: (209) 468-3420 Rodney Estrada,REHS <br /> Fax: (209)468-3433 Adrienne Ellsaesser,REHS <br /> : G� Y <br /> HAZARDOUS MATERIALS DISCLOSURE SURV� vC 5 2p15 <br /> A separate survey form is required for each business name and/or address in San Joaquin County. SGP 1 <br /> �dO�S F S� PIANN GON. <br /> Business Name: E ak-1CL �'12. ...�•—+t/L Telephone: <br /> Business Site Address:15�b -.r—s/DtISTlL\XL 1::�Mt✓E sroGKMw QSZO( <br /> Mailing Address(if different from above): <br /> Business Owner(s)Name: 1A r hS N Telephone: ?.Of 5*608 75-75 - <br /> Business Owner Address: l6�Sb 1�✓Ousy7fLlAr ��KI✓E S'faC:; ',T'Dti 9sL0(e <br /> Nature of Business: /)taf PA/GF3fi,�44 Fire District: sTWefArV�/ Co'r'e <br /> Q1. /Yes o 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 /> 0-�Yes c No Does your business generate, treat, or store a hazardous waste in any quantity?(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 and return to the address above. <br /> Q2. u Yes z'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, 500 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 /> u 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 /> n B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. c Yes �No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. u Yes /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 <br /> 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 <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 t: <br /> ed Agen / <br /> Print Namen ; V 1D A.���i51�Cv Date: of Z*4-5— <br /> Signature: ` Ti Lei GYM <br /> !" <br /> RwbU 111WH] if <br />