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cm SAN JOAQUIN COUNTY SFp19 7016 <br />a ENVIRONMENTAL IIEALTH DEPARTAiEN-T' <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone (209) 468-3420 Fax (209) 464-0138 <br />www.sicehd.com <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: W15i-f VA1.1.9Y <br />COLDS+Ruc71uN <br />Telephone: (44b') <br />3?1-6510 <br />Business Site Address: <br />2655 E. M+.rota <br />Avti, 5ivcw:rov <br />CA <br />95205 <br />Mailing Address (if different from above): 580 <br />E , M c 6L + NG y Z M,/ <br />GAn PAELL <br />CA 951 <br />Business Owner(s) Name: WS <br />VALL.CY Gd <br />NiYiv67WV Telephone: _(es) <br />321-5510 <br />Business Owner Address: <br />590 6, Mc4,+Ncy <br />LAI, , CAnpi),LL t <br />CA <br />9SIV9 <br />Nature of Business: Ca rJ 4 <br />AVL 716N <br />Fire District: G17Y <br />or <br />S7a6K TON <br />Qt. pYes n No Does your business handle a hazardous material In any uuantiN at any one time In the <br />year? See the definition of hazardous material on page 2 of this forth. <br />XYea o 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 0:1, please print, sign, and date the bottom of this form and return to the address above. <br />Q2. ItYes 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, 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? i 'Y 'A R <br />If'Yes", check any of the following conditions that apply to your business: <br />o 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 />❑ B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />03, o Yes po No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />04. o Yes WNo 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 If 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 Certificate of Occupancy or beginning of operations. I declare under <br />the penalty of perjury that the information provided on this disclosure survey is true and accurate to the beat of my knowledge. <br />If you answered "Yea' to Questlon 2, please go online to cers.calema.ca.00v to submit your hazardous materials Information. <br />Owner or Authorized Agent: <br />Print Name: J+Am WAAASa OR6if Date: ��g/�/IG <br />Signature: VP �` Title: If 16G !'PCSri),aw <br />EH015-02 <br />v(poo HMRPSIIFVPV <br />