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Q <br />r SAN JOAQUIN COUNTY r <br />ENVIRONMENTAL HEALTH DEPARTI,E-�r <br />1868 East Hazelton Avenue, Stockton, CA 95205-623 \� <br />" Telephone (209) 468-3420 Fax (209) 464-0138 y C0 <br />www.sjcehd.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: C446('A- <br />Telephone: <br />Business Site Address: l6 <br />xp� yyo--7 <br />Mailing Address (if different from <br />above): <br />Business Owner(s) Name: (.� <br />Telephone: <br />Business Owner Address: <br />999 %.kt ;g, {F{iet%L <br />Nature of Business: <br />` Fire District: <br />Q1. c Yes wl o <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 />D Yes dNo <br />Does your business generate, treat, or store a hazardous waste in any Quantity? (used oil, <br />used antifreeze, waste solvent, etc.) <br />N 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. ❑ Yes D 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? <br />If "Yes", check any of the following conditions that apply to your business: <br />D 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 />D B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. D Yes D No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. D Yes D No 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 best of my knowledge. <br />If you answered "Yes" to Question 2, please go online to cers.caleoa.ca.Qov to submit your hazardous materials information. <br />Owner or Authorized Agent: <br />Print Name: Rt A A P ALV/Z.4M i Date: OPIi-fl w <br />Signature: A�W{ r✓L Title: <br />EHD 19-02 i <br />P—;.c AIOR11A <br />HMBP SURVEY <br />