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San Joaquin County <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />IVSDWebsite: www.sigov.org/ehd <br />.JUN 2 2 2016 <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />DIRECTOR <br />Donna Heran, REHS <br />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, REHS <br />Rodney Estrada, REHS <br />Adrienne Ellsaesser, REHS <br />EWIRONMENTAL HEALTH <br />PERMIT/SERKENAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Nam <br />Business Site <br />Mailing Addres <br />Business Own, <br />Business Own, <br />Nature of Busii <br />IN <br />Q1. es ❑ No Does your business handle a hazardous material in any Quantity at any one time in the <br />y r See the definiti , of hazardous material on page 2 of this form. <br />,� C7� (�-Za-�poSrea4 -', c-� blc�S voo�- co,Mrr�ej' � bu <br />❑Yes "-0---- <br />}-IQo Does your b siness generate, treat, or store a hazardous waste in any Quantity? (used oil, Lk:;,t j <br />used antifreeze, waste solvent, etc.) GW0,'LlS 0fC<& <br />If your answer is"NNo" to both questions in Q1, please print, sign, and date the bottom of this form and return to the address above. 1 <br />Q2. des ❑ No Does your business handle a hazardous material, or a mixture containing a hazardous <br />c ill hX,,Otuw- <br />1�u--i-I <br />pD,2Y'a. }-( old• -c --L. <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 />❑ A.,/` J The hazardous materials handled by this business are contained solely in a consumer <br />'7` product packaged for direct distribution to and use by the general public. <br />❑ B./t� This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. ❑ Yes WO 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 Agent: <br />el Print Name.4 . i <br />Signature: <br />107MriIiYNINi'a <br />es - <br />Title: <br />Title: r-7iS <br />