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r <br />REC"44 <br />P, '17 I\ <br />I W LQ,3 <br />X6513(034, Pvo51 a <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 />ILO--DI RIS <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 />ENVIRONMEN,;;i. HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />HEALTH IDE" A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: Campbell Soup Supply Telephone: <br />Business Site Address <br />209-982-4586 <br />Mailing Address (if different from above): PQ Rnx 31390 <br />Business Owners) Name: _Cammnhell Soup I I C Telephone: R5R-342-49(1(1 <br />Business Owner Address: _ n1 " PIaCe, C amriel3.N.I()R1Q.3 <br />Nature of Business: Tnmatn PFire District: 3 <br />Q1. nAYes ii 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 />q(Yes ❑ 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 Q1, please print, sign, and date the bottom of this form and return to the address above. <br />Q2. EkYes ❑ 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. r, Yes Flo <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. ❑ Yes rkNo <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 />7 <br />Print Name: C �/ ' �� c) Date: <br />Signature: I Title: <br />PA -hod IWA2 <br />ID tip <br />