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1�2 1 P 1 ?2 4�3259946 E E 1 V San Joaquin County Environmental Health Department 1868 E Hazelton Avenue Stockton, California 95205 Website: www.sjgov.org/ehd Phone: (209) 468-3420 Fax: (209) 468-3433 k'A"' 0 j 2018 ENVIRONMENTAL DIRECTOR Donna Heran, REHS PROGRAM COORDINATORS Robed McClellon, RENS Jeff Carruesco, RENS, RDI Kasey Foley, REHS Linda Turkatte, REHS Rodney Estrada, REHS Adrienne Ellsaesser, REHS HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and/or address in San Joaquin County. Business Name: 4dCY Business Site Address Telephone: Mailing Address (if different from above): Business Owner(s) Name: TA -#!W BORA*-Atli Telephone: Business Owner Address: ►OPO elrMrMW",ftilj MN Nature of Business: Fire District: f(te'v_ nek<_ dou l Ralf.} �v }11,s ,Asa�K� s+r►tc r�A0dA t �cwc Awk eve- c�.K�;.,� � Q1 ❑ Yes No �D.esour bushiess handle a hazardous material in anv q a tmv at any one time in the y k year? See the definition of hazardous material on page 2 of this form. ❑Yes No Does your business generate, treat, or store a hazardous waste in any quantity? (used oil, of (ock ii0S used antifreeze, waste solvent, etc.) If 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. Q2. ❑ Yes in No Does your business handle a hazardous material, or a mixture containing a hazardous material, in a quantity equal to or greater than 55 gallons, 510 pounds, or 200 cubic feet at any one time in the year? If "Yes', how long have you handled these materials at your business? If "Yes', check any of the following conditions that apply to your business: a A The hazardous materials handled by this business are contained solely in a consumer product packaged for direct distribution to and use by the general public. ❑ B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an agricultural or horticultural commodity. 03. a Yes o No Does your business handle an Acutely Hazardous Material? See definition on page 2 04. o Yes o No Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12) I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and 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 tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owner or Authorized Agent: t /� Print Name Date _ pI / Signature