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NECEIVE® <br />SEP 2 8 2016 <br />ENVIRONMENTAL HEALTH <br />San Joaquin County DEPARTMENT <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sjgoy.org/ehd <br />Phone; (208) 488.3420 <br />Fax: (209) 468.3433 <br />DIRECTOR <br />Donna Heran, RENS <br />PROGRAM COORDINATORS <br />Robert McCINIon, REHS <br />Jett Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkat e, REHS <br />Rodney Estrada, REHS <br />Adrienne Ellaaesser. REHS <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey fomn Is required for each business name andior address in San Joaquin County. <br />Business Name: L A -d e r Telephone: l Z- —76 <br />Business Site Address: J L I 4l W 1 1 f'4 . &" // 5�sil <br />Mailing Address (it dlfkrent ho abo ); <br />Business Owner(s) Name: " A.Telephone <br />Business Owner Address: O 3 S , q[ ✓ Clly lj Chs^ br tl <br />Nature of Business: _ %UN d 5 ctU Fire District: ' <br />Q1.es o No <br />Does your business handle a hazardous material In any nand at any one time in the <br />year? See the oaf nition of hazardous material on page 2 of this form. <br />X / <br />I a ❑ No <br />\ <br />Does your business generate, treat, or store a hazardous waste in any quantile? (used oil, <br />used antifreeze, waste solvent, etc.) <br />It your answer is "No" to both questions In Of, please print, sign, and date the bottom of this forth and retym to the address above. <br />02. I 'e6 u 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 />,1 <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 />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 />o B. <br />This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />03. o Yes <br />Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />04, o Yes o <br />leo <br />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 or Occupancy or beginning of operations. I <br />declare under the penalty of perjury that the information provided on this disclosure survey Is true and sccurate to the best of <br />my knowledge. <br />Owner or Authorized <br />Agent::,, 11 G1 �1 0 <br />Print Name: I � s 6ts ✓t�(� �t9'��. Wi PILA-A Date: <br />Signature: Title: r) W L-N� <br />.. 1.1; <br />I,'d 969:60 9, 9Z des <br />