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z COUNTY OF SAN JOAQUIN Environmental Health Department 1868 E Hazelton Avenue Stockton,California 95205 Telephone(209)468-342,0 FAX(209)468-3433 Website:www.sjgov.org/ehd HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the information on the reverse side before completing this_survoy form. A separate survey for each business name anWor address in San Joaquin County is requlred, Business Name: Business Owner(s) Name: / CJ"VI\ �1 G�t1 Telephone: Business fid Address: Z'D 6 1:�&Mjny Mailing Address(if different from above): Nature of Business: 1 �c � Fire District: Q1.�" es CtNo Does your business handle a hazardous material in any quantity at-any one time in the yearT See the definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. Q2. 19,Y65-s []No Does your business handle a hazardous material,or a mixture containing a hazardous material in a quantity-equal to or greater than 55 gallons, 500 pounds,or 200cubic feet at any one time in the year? If°Yes,"ho -longhave you handled these materials at our business? I Y Y i If"Yes,"check any of the following conditions that applies to your business. ❑A. 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. ❑B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses onlx medical gases. ❑C. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an agricultural or horticultural commodity. Q3. ❑Yes []No Does your business handle an acutely hazardous material? See definition on reverse side of this form. 04. Wes []No Is your business within 1,000 feet of the outer boundary of a school(grades K-92)? 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 responsibility 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 Author'zed Agnt: X alcAtk Date:_ \Pnt Name X ��.�— J/1.�p Title; o e',v r Signature F/ApplimbonsForms&HandoutsJPianntngAppiications/Business License(Revised 02-24-15) Page 4 of 6