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COUNTY OF SA 0 . QU1N ' Environmental Health Department 1868 E Hazelton Avenue Stockton, California 95205 Telephone(2-09)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 com_ pfeting this_survey farm. A separate survey for each business name anWor address in San Joaquin County is required: Business Name: Business Owner(s) — Name: Ila Std J�'.Y(G(1?V 1 TeIell,one: (7, 04)"S' Business fes• '� Address: A Mailing Address (if different from .�� above): P��' Z� ��j � q� CA �-2.0f. Nature of Business: A ,U4o ��,��` � + �` L' Fire District: � s I/ + Q1. /Yes. o Does your business handle a hazardous material in any quantity at �ny on 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. Q2. As ❑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? I 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. V. 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 only medical gases. ❑C. This business operates a farm for purposes of cuftivating the soil, raising, or harvesting an agricultural or horticultural commodity. Q3. &&es ❑No Does your business handle an acutely hazardous material? See definition on reverse side of this / form. Q4. [t3Yes ❑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 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 u1hnri7P Aae0 j X ,�'✓ C=am Date: Title: F/ApplicaBonsForms&Handouts/PlanningApplicaflons/Busfness license(Revised 02-24-95) Page 4 of 6