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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 />SV <br />CCC--- <br />Ells �tyr� C <br />HAZARDOUS MATERIALS DISCLOSURE SURVEYAUG 1 12015 <br />�����p <br />A separate survey form is required for each business name and/or address in San Joaglh`n(�If'I0NMENTAL- <br />IJCp�TV nCo40T4XCNIT <br />Business Name: !� `"JQaf— o. 04014 Telephone: -2eal'(-;, 1.-t- gCto1D <br />Business Site Address: <br />Mailing Address (if different from above): <br />Business Owner(s)Name: MUrMwr^^O"9 Sci I Telephone: —209- 6'(9-' qct U <br />Business Owner Address: l 08'7� S PI k,LPa h <br />Nature of Business: <br />Fire District: <br />Q1. C Yes b`9 �o Does your business handle a hazardous material in any auantiri at any one time in the <br />year? See the definition of hazardous material on page 2 of this form. <br />c Yes e1Ifo Does your business generate, treat, or store a hazardous waste in any cuantity? (used oil, <br />used antifreeze, waste solvent, etc.) <br />If your answer is "No" to both questions in Ot, please print, sign, and date the bottom of this form and return to the address above. <br />Q2. E Yes 3Xb 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 />CA. 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 />e B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. a Yes o,Nb Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. a Yes trKo Is your business within 1,000 feet ofthe outer boundary of a school? (Grades K-12) <br />e<-` <br />I have read the information on this form antunderstand 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 />Print Name <br />Signature: <br />Re sed 11rom2 <br />