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COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> Telephone(209)468-3420 <br /> FAX(209)468-3433 <br /> Website:www.sjgov.org/ehd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the informatio on the reverse side before completing this survey form. A separate survey for each business <br /> name and/or address in San Joaquin County is required. <br /> Business <br /> Name: S 2-. )Ue"��d£ LJf GVf,$ <br /> Business Owners) z oq - S32--3-W1 <br /> Name: ��� ys Telephone: <br /> f,-AJ zos -(7110-Cr44s <br /> Business <br /> Address: 79'i39 ll S- J'�Aj- a <br /> Mailing Address(if diff rent from <br /> above): _ <br /> Nature of - <br /> Business: /rt,, j- RWh r2 Fire District: Ticy <br /> Q1. Yes No Does you business handle a hazardous material in any quantity at any one time in the year? See the <br /> efinition f hazardous material on the back of this form. If your answer is No," go to Question 4. <br /> Q2. Yes No oes youri business handle a hazardous material, or a mixture containing a hazardous material in a <br /> antity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at any one time in the year? <br /> I "Yes," how long have you handled these materials at your business? <br /> If"Yes," check any of the following conditions that applies to your business. <br /> IA. The hazardous materials handled by this business is contained solely in a consumer product <br /> pack�ged for direct distribution to, and use by,the general public. <br /> B. This business is a health care facility(doctor, dentist, veterinary, etc.) and uses only medical <br /> gase . <br /> C. This usiness operates a farm for purposes of cultivating the soil, raising,or harvesting an <br /> agric IturaI or horticultural commodity. <br /> Q3. YeDoles your usiness handle an acutely hazardous material? See definition on reverse side of this <br /> v form. <br /> Q4. Yes a Is your busi ess within 1,000 feet of the outer boundary of a school(grades K-12)? <br /> I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code. I understand th t if I own a facility or property that is used by tenants, that it is my responsibility to notify the <br /> tenants of the requirements ich must be met prior to issuance of a Certificate of Occupancy or beginning of operations. <br /> I declare under the penalty of erjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge. <br /> Owner or Authorizer,Agent: <br /> X CA-AN�k��o,�U--.. 1 Date: TAmor to <br /> X /- O Print Name — <br /> —� Title: Owers-+2. <br /> Signature <br /> F/ApplicabonsForms&Handouts/Pianni gApplicaUonsBusiness License(Revised 02-24.15) <br /> Page 4 of 6 <br />