Laserfiche WebLink
ar91'iti: COUNTY OF SAN JOAQUIN <br /> �(' Environmental Health Department <br /> N^: Y 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> c•F..•:i`'"� 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 Name: O6? <br /> Business Owner(s)Name: &A-T-1 tc f'i' /jl l ? _ Telephone: o ) <br /> Business Address: Jam? ( �l${:t/v��(tt ,l ' CA <br /> Mailing Address(if different from above): SF;X.LC_1cs <br /> Nature of Business: lf�nr,(�(f SC_. _ Fire District: <br /> Q1. IgYes ONO 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. }1LYes ONO 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 200cubic feet at any one time in the year? <br /> If"Yes,"how long have you handled these materials at your business? I!�, -(ag <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> OA- 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 /> OB. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses only medical gases. <br /> This business operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. VYes ONO Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes )(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. 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. 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 /,,Mlt� A5W44�F//,/,"o _ Date:--,?- <br /> Print NlaJne <br /> X l� Title: Q�JLy�y-i'c✓G5 �nirs 7z9'" <br /> Signat re d' <br /> FADEMC\Planning Application Form51511e Approval.(Revised 0243-10) Page 6 of 9 <br />