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�° ,,..,rF•E co, <br />12 •.G� <br />gCrFORi,,i <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 />I 1p'i�1�123 <br />DIRECTOR <br />Donna Heran, REHS <br />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, RENS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, 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 and/or address in San Joaquin County <br />N),_? <br />ec 70 3 09 <br />Business Name: _? <br />Telephone: <br />Business Site Address: <br />-20 lNAts VA <br />r S toc Ic J I A q 2_06 <br />Mailing Address (if different from above): <br />Business Owner(s) Name:,l <br />Tlele hone: <br />Business Owner Address: <br />++ <br />�A ZU -,g J(, S� � rti 1 d r S O(C I L r) r Ci � 20 <br />Nature of Business: � <br />�mj <br />IC U«CWrIQlw Fire District: <br />Q1. Yes ❑ No <br />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 />Yes -i No <br />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 <br />questions in Q1, please print, sign, and date the bottom of this form and return to the address above. <br />Q2. 'Yes ❑ No <br />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 />Z <br />If "Yes", how long have you handled these materials at your business? 'at) <br />If "Yes", check any of the following conditions that apply to your business: <br />A. <br />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 />B. <br />This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. ❑ Yes No <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. E: Yes No <br />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 Agent: <br />pu) OLNPrint Name:Date: <br />Signature: Title: <br />1 <br />Revised 11/07/12 <br />