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COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> Telephone (209)468-3420 <br /> FAX(209)468-3433 <br /> Website: www.sjgov.org/ehd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business <br /> name and/or address-in San Joaquin County is required. <br /> Business <br /> Name: <br /> Business Owner(s) (� 1 <br /> Name: P�✓� 4J(�o�.� i dCh � Telephone: <br /> Business ,AI <br /> Address: 7iZ <br /> Mailing Address (if different from <br /> abave): <br /> Nature of <br /> Business: Fire-District: <br /> Q1. 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 /> Q2. 'V�(es ❑No Does your business handle a hazardous material, or-a mixture containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons, 500 pounds, or 200cu-bic-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 /> ❑A. 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 /> Q3. ❑Yes Does-your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. ❑Yes"UfNo 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. 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 /> I 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 /> Owr Autd Agent <br /> X S Date: [ / <br /> rint ff <br /> X Title: C� d <br /> S' n <br /> F/ApplicationsForms&Handouts/PlanningApplications/Business License(Revised 02-2415) <br /> Page 5 of 6 <br />