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oto 'r o COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1568 E Hazelton Avenue <br /> Stockton, California 95205 <br /> Telephone (209)468-3420 <br /> FAX (20914,68-3433 <br /> 'L-`­8it@=xwN1,-igov.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 andfor address in San Joaquin County is required. <br /> Business Name: / <br /> Business Owner(s) Name: A la V {!mom !!Telephone: eJf4' f q 4$ 070 <br /> Business Address: J aL; "f" <br /> Mailing Address (if different from above): <br /> Nature of Business: .542/_t 0 C'✓p v AS _aklk k ebb/Kc Fire District: I;4CNi <br /> Q1. ❑Yes Y$NoDoes your business handle a hazardous material in any quantity at any one time in the yearT-See the <br /> ,definition of hazardous.material on the back of this form. If your answer is No,'go to Question 4. <br /> Q2. []Yes Wlo Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br /> quantity equal-to or greaterthan-55 gallons, 500 pounds, or 200cubic feet at anyone time in the year? <br /> If"Yes," how long-1`rave 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 onlv medical 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 No-Doesyour business-handle an acutely hazardous material? See definition on reverse side of this form. <br /> 04. []Yes *0 Is your business within 1,000 feetof the outer boundary of a school (grades K-1-2)? <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 t own a-facilityor properly 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. I <br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> X )\5 /�-'y J<u Date: <br /> Print Name <br /> X L_ Title: <br /> Signature <br />