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San Joaquin County
<br />Environmental Health Department
<br />1868 E Hazelton Avenue
<br />Stockton, California 95205
<br />Website: www.slgov.org/ehd
<br />Phone: (209) 468.3420
<br />Fax: (209) 468-3433
<br />SEP 18 2014
<br />NREY NMENTAL HEALTH
<br />Donna PMTMENT
<br />PROGRAM COORDINATORS
<br />Robert McClellan, REHS
<br />Jeff Cartuesoo, REHS, RDI
<br />Kasey Foley, REHS
<br />Linda Turkatte, REHS
<br />Rodney Estrada, REHS
<br />Adrienne Ellsaesser, REHS
<br />14 rlyp,
<br />HAZARDOUS MATERIALS DISCLOSURE SURVEY
<br />A separate survey form is required for each business name and/or address in San Joaquin County.
<br />D
<br />Business Name: W 45c 1 r lARa1r�^'l N� Telephone:
<br />Business Site Address: 1555
<br />G
<br />Mailing Address (if different from above):
<br />Business Owner(s) Name:
<br />Business Owner Address:
<br />Nature of Business: J ,
<br />Qt�`
<br />. es ❑ No
<br />`N
<br />I(/'/Y\ es ❑ No
<br />Telephone:
<br />Fire District: LOcti
<br />Does your business handle a hazardous material in any euantity at any one time in the
<br />year/ See the definition of hazardous material on page 2 of this form.
<br />Does your business generate, treat, or store a hazardous waste in any cuantity? (used oil,
<br />used antifreeze, waste solvent, etc.)
<br />If your answer is "No" to both questions in at, please print, sign, and date the bottom of this form and return to the address above.
<br />Q2. V --es ❑ No Does your business handle a hazardous material, or a mbdure containing a hazardous
<br />/� material, in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at
<br />any onetime in the year? I
<br />11"Yes , how long have you handled these materials at your business? 1917
<br />/
<br />If *Yee, 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 />gcf. This business operates a farm for purposes of cultivating the soil, raising or harvesting an
<br />agricultural or horticultural commodity.
<br />03. Yes o No Does your business handle an Acutely Hazardous Material? See definition on page 2.
<br />44. ❑ Yes >(No Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12)
<br />1 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: T• Jc-O(ft „t at # lsey) Date: /Y
<br />Signature:
<br />��/-
<br />Signature: �"" Title: �S1 0' I ' { v1A Y"
<br />Renes 11=2
<br />-
<br />RECEIVED
<br />San Joaquin County
<br />Environmental Health Department
<br />1868 E Hazelton Avenue
<br />Stockton, California 95205
<br />Website: www.slgov.org/ehd
<br />Phone: (209) 468.3420
<br />Fax: (209) 468-3433
<br />SEP 18 2014
<br />NREY NMENTAL HEALTH
<br />Donna PMTMENT
<br />PROGRAM COORDINATORS
<br />Robert McClellan, REHS
<br />Jeff Cartuesoo, REHS, RDI
<br />Kasey Foley, REHS
<br />Linda Turkatte, REHS
<br />Rodney Estrada, REHS
<br />Adrienne Ellsaesser, REHS
<br />14 rlyp,
<br />HAZARDOUS MATERIALS DISCLOSURE SURVEY
<br />A separate survey form is required for each business name and/or address in San Joaquin County.
<br />D
<br />Business Name: W 45c 1 r lARa1r�^'l N� Telephone:
<br />Business Site Address: 1555
<br />G
<br />Mailing Address (if different from above):
<br />Business Owner(s) Name:
<br />Business Owner Address:
<br />Nature of Business: J ,
<br />Qt�`
<br />. es ❑ No
<br />`N
<br />I(/'/Y\ es ❑ No
<br />Telephone:
<br />Fire District: LOcti
<br />Does your business handle a hazardous material in any euantity at any one time in the
<br />year/ See the definition of hazardous material on page 2 of this form.
<br />Does your business generate, treat, or store a hazardous waste in any cuantity? (used oil,
<br />used antifreeze, waste solvent, etc.)
<br />If your answer is "No" to both questions in at, please print, sign, and date the bottom of this form and return to the address above.
<br />Q2. V --es ❑ No Does your business handle a hazardous material, or a mbdure containing a hazardous
<br />/� material, in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at
<br />any onetime in the year? I
<br />11"Yes , how long have you handled these materials at your business? 1917
<br />/
<br />If *Yee, 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 />gcf. This business operates a farm for purposes of cultivating the soil, raising or harvesting an
<br />agricultural or horticultural commodity.
<br />03. Yes o No Does your business handle an Acutely Hazardous Material? See definition on page 2.
<br />44. ❑ Yes >(No Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12)
<br />1 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: T• Jc-O(ft „t at # lsey) Date: /Y
<br />Signature:
<br />��/-
<br />Signature: �"" Title: �S1 0' I ' { v1A Y"
<br />Renes 11=2
<br />
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