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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 MoClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkalle, 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 />8usine as Name: Y11Q I (C04 tfdle-' a -V- Telephone:d606 <br />Business Site Address: 3 i53 WVQi- I_a11 -o-. t bc: Phi e a 9 S-96 <br />Mailing Address (If different from above): L/Uy 1/E, YQ.S�ra <br />Business Owner(s) Name: n�YfCQ.s� Gcce�+ <br />Business Owner Address: _ f 36 3 S, F1(6& r (. 62, <br />Nature of Business: Am GL I" ee Tra mwa �- A, h c- <br />$cK- fy/, C,\ 9 i --W3 <br />,Telephone: 3d �, -1117Y-1206 <br />Le L 3 P- o'or (S otrr= - V t(0t ; eG <br />Fire Distrlct: s -f c % - WI-'. <br />Q1. -,Yes ❑ No Does your business handle a hazardous material in any auantity at any one time in the <br />year? See the definition of hazardous material on page 2 of this form. <br />`s(yes ❑ No Does your business generate, treat, or store a hazardous waste in any auantity? (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. 1j(es ❑ 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? /I <br />r4 (Z ��a n ✓ j i If 'Yes", how long have you handled these materials at your business? d W ps� l &,r -to <br />f 1�`� e <br />if *Yes", check any of the following conditions that apply to your business: jr✓S �i'e/tS <br />� The hazardous materials handled by this business are contained solely In a consumer <br />` C� a 40 2 lY 'AI (Y product packaged for direct distribution to and use by the general public. <br />'t I <br />'38, This business operates a farm for purposes of cultivating the soil, ralsing or harvesting an <br />agricultural or horticultural commodity. <br />03. a Yes N140 Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4.Yes ❑ No Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12) <br />1 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 />Print Name: (-w�� Date: <br />1 j���L�� '✓� <br />' Signature: C Title: <br />RIAld 1A07/tt <br />