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San Joaquin County <br /> Environmental Health Department OIRECTOR Donna Heran, REHS <br /> 1868 E Hazelton Avenue <br /> PROGRAM COORDINATORS <br /> ECEoo'�n Stockton, California 95205 Robert McClellon,REHS <br /> r <br /> Jeff Carruesco,REHS, RDI <br /> Kasey Foley,RENS <br /> Website: www.sjgov.org/ehd Linda Turkatte,REHS <br /> OCT 15 2014 Phone: (209)468-3420 Rodney Estrada, REHS <br /> Fax: (209)468-3433 Adrienne Ellsaesser, REHS <br /> ENVIRONMENTAL HEALTH <br /> PERMITISERVICES <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: L1A1iF0P-1V SEAV14$Telephone: _yo - 4,�7Z F2..61 <br /> Business Site Address: ��S?2�^O UT GQ f. S 7-OCK] 79/V CA- <br /> Mailing <br /> A-Mailing Address(if different from above): 33o Cil f E S nyyT sr. fAK#Ad CA -7f/6O� <br /> Business Owner(s) Name: Telephone: <br /> Business Owner Address: <br /> Nature of Business: Ok/ ro km S E(ZW cs-cz Fire District: <br /> Q1. at Yes c 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 /> cXYes n 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 01,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2. 9Yes c 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? New Business <br /> If"Yes", check any of the following conditions that apply to your business: <br /> c 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 /> n B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. 6 Yes o No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. c Yes X No 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:_ LF K (Z om 19 91/, Date: _ /OZ <br /> Signature: Title: W/l/ A0 LL kl � <br />