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RECEIVED <br />MAR 31 2016 <br />ENVIRONMENTAL HEALTH <br />San Joaquin County <br />DIRECTOR <br />Environmental Health Department Donna Heran, REHS <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 />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Canuesco. REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, REHS <br />Rodney Estrada, REHS <br />Adnenne 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 />Business Name: 1.1), <br />Business Site Address: <br />Mailing Address (if different from above): <br />Telephone: A09-120✓-ariOfD <br />Business Owner(s) Name: )' jCx,_Np('4 L.6CII4, A_P Telephone: &424 - Hti j0 <br />Business Owner Address: <br />Nature of Business: <br />Vw-- ) 4 'PcYti./ 'ho*5, - i)atts Fire Dlsbict: Fhcr j) CGIM(-� <br />Frcujhtltncf aAa waStolA Sta '3&-Mig <br />Q1.y� Yes <br />, No Does your business handle a hazardous material in any quantity at any one time in the <br />`��`_///��� <br />year? See the definition of hazardous material on page 2 of this form. <br />Yes <br />; No Does your business generate, treat or store a hazardous waste in any quantity? (used oil, <br />• <br />used antifreeze, waste solvent, etc.) <br />H your answer is "No" <br />to both questions In 01, please print sign, and date the bottom of this form and return to the address above. <br />Q2 Yes <br />_ 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?ISL`' <br />/ If "Yes", check any of the following conditions that apply to your business: <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 />- B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />- / agricultural or horticultural commodity. <br />Q3. Yes X, Jo Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. _ Yes /1 o 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 e t '/J� <br />Print Name: PO � Date: <br />• 11/W /1 <br />Signatu Title: ��ZA1 Ce <br />