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M'iOflOi 50 COUNTY OF SAN JOAQUIN Environmental Health Department 1868 E Hazelton Avenue Stockton, California 95205 Telephone (209) 468-3420 FAX (209) 468-3433 Webslte: www.sjgov.orgiehd HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the information on the reverse side before completing this survey form. A separate survey for each business name anchor address In San Joaquin County is required. , ;Ftinc_ Business Owner(s) Name: /196-iv& oF S1 Lq,b Clitt/n Telephone! )63 7(. -YYSF 12 W W Pfrte- lee-14 11a V c? 4-51--J Q A( S1 ttpr Mailing Address (If different from above): 'SW 7 IV • L( ti St: 517)c ft rehl get zci,C2C41 Nature of Business: 2/,1fqi &Ly Fire District adi'keicio - 01 0R.fric:(4- °Yes 136 Does your business handle a hazardous material in any quantity at any one time in the year? See the definition of hazardous material on the back of this form. If your answer Is No," go to Question 4. 0Yes *to Does your business handle a hazardous material, or a mixbire containing a hazardous material in a quantity equal to or greater than 55 gallons, 600 pounds, or 200cubic feet at any one time in the year? If "Yes; how long have you handled these materials at your business? If 'Yes; check any of the following conditions that applies to your business. OA. The hazardous materials handled by this business Is contained solely in a consumer product. packaged for direct distribution to, and use by, the general public. OB. This business is a health care faciity (doctor, dentist, veterinary, etc.) and uses oniv medical gases. 0C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or horticultural cornmoclity. 0Yes No Does your business handle an acutely hazardous material? See definition on reverse side of this form. 0Yes No Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety Code. I understand that If I own a facility or property that Is used by tenants, that it is my responsitlity to notify the tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owner or Authorized Agent X jce e #0 Date: X 6-''27f a4* iaf glh421e- Business Name: -St 1,L4 C I1M c j Business Address: S' natixe