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13 <br />San Joaquin County <br />Environmental Health Department <br />DIRECTOR <br />Donna Heran, REHS <br />1868 E Hazelton Avenue <br />PROGRAM COORDINATORS <br />Stockton, California 95205 <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />9 Website: www.sjgov.org/ehd <br />Linda Turkalle, REHS <br />�P Phone: (209) 468-3420 <br />Fax- (209) 468-3433 <br />Rodney Estrada, REHS <br />Adrienne Ellsaesser, REHS <br />/i/7% �,J <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: _b1(1E7F//N6 %.tE544ND F�ar,5 Telephone: C1oq J %'.t%.37511 <br />Business Site Address: 906O/ 6, ffe7R-6,Y14A1 4f1.ve 1 40b , G4 9gr;ZS40 <br />Mailing Address (if different from above): <br />Business Owner(s) Name: //fW/ &C-TW110f 04AA✓ 4SOI✓ Telephone: (7a% %xI -, r17W <br />Business Owner Address: ;tO&I 6 KE7TLf_M,W 4V, GGD/ , 819 175;Z00 <br />Nature of Business: Fire District <br />Q1. Wes ❑ No 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 />f(Yes o No 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 Girl, please print, sign, and date the bottom of this forth and return to the address above. <br />Q2. XYes n 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? <br />If 'Yes", check any of the following conditions that apply to your business: <br />u 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 />➢(B. This business operates a farm for purposes of cultivating the soil, ralsing or harvesting an <br />agricultural or horticultural commodity. <br />Q3. jif Yes u No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. o Yes XNo 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 />Print Name: 16�RE/t/ �"/?".(�,77dU�� Date: <br />Signature: Y VNr.IJy /// ��r!'!'ayi'LG(%/ Title: _ gse�l <br />R.. W , IA7112 <br />