Laserfiche WebLink
�a�Jt San Joaquin County <br /> DIR <br /> �- -�' Environmental Health Department DonnaOHeran,REHS <br /> s c, <br /> y.Emu ` 1868 E Hazelton Avenue <br /> Stockton, California 95205 PROGRAM COORDINATORS <br /> Robert McClellon,REHS <br /> �­q• ,P� JefCarruesco,REHS.RDI <br /> Kasey Foley,REHS <br /> Website: WWW.sjgov.org/ehd Linda Turkatte,REHS <br /> Phone: (209)468-3420 Rodney Estrada.REHS <br /> Fax: (209)468-3433 Adrienne Ellsaesser•REHS <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County. <br /> Business Name:_ J 4:5. y14 7"o /� SP/I/I+_ <br /> i Telephone: <br /> ?1 <br /> Business Site Address: lyl O 0( Ct Lpd, 4 1 <br /> Mailing Address(if different from above): __JS( Kenha „ (IpU( F ^i 't.lei.4 e1 A f S_3 3 � <br /> Business Owner(s)Name:1-t—t d�v' f �- �,��`f'n� Telephone: C o70 4-) <br /> Business Owner Address: _ /!/ f y�a�U E r, �n>>�>4 9 f5_372 <br /> Natureo£BusineSs: T(VA k k)k5A Lot, e aN� 5e(el,r e Fire District: <br /> 01. Yes o No Does your business handle a hazardous material in any Quantity at any one time in the <br /> year? See the definition of hazardous material on page 2 of this form. <br /> y Yes ri No Does your business generate,treat,or store a hazardous waste in any quantity?(used oil, <br /> / used antifreeze,waste solvent,etc.) <br /> If your answer Is"No"to both questions in Q1,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2• tQ Yes u No Does your business handle a hazardous material, or a mixture containing a hazardous <br /> material, in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at <br /> 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 apply to your business <br /> A• The hazardous materials handled by this business are contained solely in a consumer <br /> product packaged for direct distribution to and use by the general public. <br /> C B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. e Yes No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> 04. c Yes X No Is your business within 1,000 feet of the outer boundary of a school?(Grades K-12) <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code (HSC). I understand that if I own a facility or property that is used by tenants, 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 of <br /> my knowledge. <br /> Owner or Authorized Agent: <br /> SiGr�rK <br /> Print Name (2i ♦,,t <br /> �-� Dale I `t ' 1 3 <br /> Signature: f Gr C� L� <br /> Title: _ V, 9' '-A" CC <br /> R,v d t tWf12 <br />