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RE 9. <br />r� A, <br />P?V513(1034-1 P�651 G3+-4- <br />,�p ILO --DI RIS <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, RENS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, RENS <br />Rodney Estrada, REHS <br />Adrienne Ellsaesser, REHS <br />ENVIRONMENTAL HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />HEALTH DE'_ 'A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: Campbell Soup Supply Telephone: 209-982-4586 <br />Business Site Address: _ 76(l Inriuctrial Drivp <br />Mailing Address (if different from above): PC) RoY 31390 <br />Business Owner(s) Name: (_ ,amT hell Sni in I I C Telephone: A1j6-342-4RM <br />Business Owner Address: 1 C'.amphPll Pinny, Camden. NJ 08103 <br />Nature of Business: Tomato Pro . _tying Fire District: _ 3 <br />Q1. okYes ❑ 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 />ixYes ❑ 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 questions In 01, please print, sign, and date the bottom of this form and return to the address above. <br />Q2. ckYes ❑ 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 />If "Yes", how long have you handled these materials at your business? 30 years <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 />n B. <br />This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. u Yes Flo <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. ❑ Yes gkNo <br />Is your business within 1,000 fleet 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 Califomia 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 />C7 <br />Print Name: _ J Ca �/� 0�/1 �,�—��-. Date: <br />Signature: L Title: <br />R"Od »b7ns <br />