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RECEIVED <br /> N(�V 07 2013 <br /> u�N <br /> San Joaquin County <br /> (Environmental Health Department TM"MENTAL <br /> 2 r r 2� 1868 E Hazelton Avenue PROGRAM COORPDINA ORST <br /> % <br /> Stockton, California 95205 Robert McClellon,REHS <br /> Jeff Carruesco,REHS,RDI <br /> Kasey Foley,REHS <br /> 9r-0 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 <br /> address in San Joaquin County. <br /> Business Name: ` //[� +�� L�%// C�T>3�phone: <br /> Business Site Address: / '� �/' �� ✓-� �� <br /> Mailing Address(if different fr above): � <br /> Business Owner(s) Name: �WW ��//l'/�ll/���� Telephone: <br /> Business Owner Address: <br /> Nature of Business: l Fire District: <br /> Q1. XY <br /> es 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 /> es ii 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 q jestions in Q1,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2. ❑YesN0 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 /> ❑ B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes o Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. ❑Yes o Is your business within 1,000 feet of the outer boundary of a school?(Grades K-12) <br /> have read the information or 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 o Authorized Agen : 7 <br /> Print Name: 1AW121�� Z- Date: <br /> Signature: Title: <br /> Revised 11/07/12 <br />