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SAN JOAgUii� Environmental Health �epartm®nt <br /> COUNTY <br /> grows M1ere <br /> MAZARROUS MATERIALS O�S6LOSURE SURVEY <br /> A separate survey form is required ror each business name and/or address In San Joaquin County. <br /> Mahil Truck Parking 209 406 1731 <br /> Business Names: THlephona: <br /> 4750 E Mariposa Rd Stockton, CA 95215 <br /> Business Sita Address: <br /> 3338 Ruthertord Drive Stockton, CA 95212 <br /> Mailing Address(If different from above): <br /> Lakhbir Singh Mahil 209 406 1731 <br /> Business Ownar(s)Name: Telephone: <br /> 3338 Rutherford Orive Stockton, CA 95212 <br /> Business Owner Address: <br /> Trucking Montezuma <br /> Nature oT Business: Fires District <br /> Ol. v Yas l�No Doas your business handle a hH2Hrdous malarial in env duanTty at any one lima in the year? <br /> Sae the definition of hazardous material on page 2 of this form. <br /> v Yas �CjJo Doas your business generate,treat,or store a hazardous waste in env quantity?(used oil,used <br /> antifreeze.waste solvent.etc.) <br /> If your answer b"No^to both quastlona In Ot,please print,a1Bn.and data the bottom oT tMa Torm and return to the address above. <br /> 02. v Yas �No Doas your business handle a heiardous material,or a miMura containing a hazardous material, <br /> In a quaMky equal ro or greater than 55 gHllons,500 pountls,or 200 cubic Tact a[any one time <br /> m the year? <br /> It"Yas", how long have you handled those materials at your business? <br /> IT"Vas",check any of iha following contlitions that apply to your business: <br /> v A. The hazardous materials handled by this business are contained solely In a consumer product <br /> packaged for direct distribution ro and use by the general public. <br /> v B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticukural commodity. <br /> 03. v Yas �/jJo Doas your business handle an Acutely Hazardous Material? Sae dafinkion on page 2. <br /> D4. o Yas �No Is your business within 1,000 Tact oT the outer boundary of a school?(arades K42) <br /> I have read the Information on this rorm and understand my requirements under Chapter 6.95 of the Calirornla Health antl Safety <br /> Code(HSC). I understand that if I own a Tacility or property that Is used by tenants,it is my responsibility to notify the tenants of the <br /> requirements which must ba met prior To i8suenca of a Certiiicata of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the Inronnatlon provided on this disclosure survey is true and accureta to the bast of my knowledge. <br /> If you answered"Vas"io puas[ion 2, please go online to cars cal¢oa v to submit your hazaMOus materials iMormation. <br /> Owner or Authorized Agent: <br /> Lakhbir Singh Mahil <br /> Print Name: �(�Ij Data: �fO�i4 <br /> Signature: ���/r�+�i Title: !^s�.� el�iL <br /> Y 868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0136 I www.sjcand.com <br />