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San Joaquin County DIRECTOR Environmental Healthen Donna Heran , REHS r 186 Hazelton Avenue PROGRAM COORDINATORS - -'® Stockton , California . 95205 Robert McClellon , REHS Jeff Carruesco , REHS , RDI Kasey Foley, REHS Website : .sjgov. or_q/ehd Linda Turkatte , REHS Phone : (209 ) 463 =3420 Rodney Estrada, REHS Fax: (209) 463-3433 Adrienne Ellsaesser, REHS , HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and/or address in San Joaquin County, Business Name : C7A S CkATelephone : loci Business Site Address : Mailing Address (if different from above ) : Business Owner(s ) Name : ' C Telephone : �. oci � - Business Owner Address : i I COLL Nature of Business : _ 4` - Fire District: — Cie Q Q1 . ❑ Yes KNIo Does your business handle a hazardous material in any quantity at any one time in the year? See the definition of hazardous material on page 2 of this form . ❑ Yes W, o Does your business generate , treat, or store a hazardous waste in any quantity? (used oil , used antifreeze , waste solvent, etc. ) 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 . Q2 . ❑ Yes ❑ 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 200 cubic 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 apply to your business : ❑ A. The hazardous materials handled by this business are contained solely in a consumer product packaged for direct distribution to and use by the general public. ❑ B . 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 page 2 . Q4 . ❑ Yes ❑ 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 (HSC ) , i understand that if I own a facility or property that is used by tenants , 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 Autri d Agent: Print Name : U Date % l Signature , Title :