Laserfiche WebLink
19 0 0' 2 <br /> 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 r quired <br /> Business sG ,— ' <br /> Name: ' <br /> Business Owner(s) <br /> Name: 11.� Tele hone:�UvtuP ��� vac 4Ac c o r� � __I ��l 7'Z-7 a2ob <br /> Business <br /> Address CA2 b <br /> Mailing Address (if different from <br /> above): S� .P <br /> Nature of <br /> Business: Co �y C_ Fire District: k4e Lao ,e <br /> Q1. �es ❑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. I�Yes []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 200cubic feet at any one time in the year? <br /> If"Yes,"-how long have you handled these materials at your business? rs St k cQ c.LLc,,sc <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 /> IAC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes 'gNo Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. ❑Yes+o 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 /> -Owner or Authorized Agent: <br /> X`, cr -e— Date: ( �4 <br /> rint Name �' <br /> �X Title: r�u �--L-c'—r- �� �S'��-�S LLC <br /> Si ature <br />