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4 COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1 868 E Hazelton Avenue <br /> Stocktorr, California 95205 <br /> ti Telephone ( 209) 468-3420 <br /> FAX (209) 468-3433 <br /> Website : www. sjgov . org/ehd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> [name <br /> lease read the information on the reverse side before completing this survey form . A separate survey for each business <br /> and /or address in San Joaquin County is required . <br /> Business <br /> Name : <br /> Business Owner(s) / � <br /> Name: Telephone : 2V . `'S' 1g 9 l <br /> Business Q <br /> Address : 2 <br /> Mailing <br /> Address ( if different from <br /> above) : 2 D(p2�5 �> {(� Com{ {2 S7ZN ( G(5 �2 <br /> abov <br /> Nature of <br /> Business : I0 AO T1SPAM I Ct & �-(� Fire District : k <br /> 1 . C�Yes ❑ No Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material on the back of this form . If your answer is No , " go to Question 4 . <br /> 2 , Yes ❑ No Does your business handle a hazardous material , or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 5S gallons, 500 pounds , -or 200cubic feet at 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 applies to your business , <br /> Z. The hazardous materials handled by this business is contained solely in a consumer product, <br /> packaged for direct distribution to , and use by, the general public . <br /> ❑ B . This business is a health care facility (doctor, dentist, veterinary, etc . ) and uses only medical <br /> gases . <br /> ❑ C . This business operates a farm for purposes of cultivating the soil , raising , or harvesting an <br /> agricultural or horticultural commodity. <br /> 3 . ❑Yes Elo Does your business handle an acutely hazardous material ? See definition on reverse side of this <br /> // form . <br /> Q4 . []Yes 01 0 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 . I understand that if I own a facility or property that is used by tenants , that 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 . <br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge . <br /> Owner or orized Agen _ 1 <br /> Date : � . . <br /> X Title : 0 V C2?,zk:�4 — <br /> Sidp4ture <br /> llcationsForrns$ Hands,ilsiPlanningApplicationsiBusiness License (Revised 02-2415) <br /> age 5 of 6 <br />