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SAN JOAQUIN n3 �.� � roit nr � nt, a"L � �� a'tk De arta; cins� C O U N T Y-- 6reatness gro4^is here + r! tE , H9 ZAR oDOM HLaVIERU A L8 DDSC LOSUkE U [RgEY A separate survey form is required for each business name and /or address in San Joaquin County . Business Name : 14V41w � Telephone : � � � 710 wj7o� Business Site Address : L Mailing Address ( if different from above ) : Business Owner( s ) Name Telephone : Telephone : G � � Business Owner Address : _ ,� 717 Nature of Business : 160)eVvj' Fire District : Q1 . ❑ Yes 440 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 Wo Does your business generate , treat , or store a hazardous waste in any guantuy? ( 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 yourbusiness handle a hazardous material , ora 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 . If you answered " Yes " to Question 2 , please go online to cers . calepa . ca . gov to submit your hazardous materials information . Owner or Authorized Agent : Print Name : �' Date : r, Sig nature : Title : 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 -0138 1 www . sjcehd . corn