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San Joaquin County <br />Environmental Health Department <br />1868 EHazelton Avenue <br />Stockton, Californiai <br />111 <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />DIRECTOR <br />Donna Horan, REHS <br />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, REHS <br />Rodney Estrada, REHS <br />Adrienne Ellsaesser, REHS <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: AUBURN 7700 INC Telephone: 209-234-1256 <br />Business Site Address: 444 MOSSDALE RD LATHROP CA 95330 <br />Mailing Address (if different from above): SAME <br />Business Owner(s) Name: WAG1H KAMAR Telephone: 702-533-3013 <br />Business Owner Address: 2020 REDROCK RD LAS VEGAS NV 89148 <br />Nature of Business: GAS STATION/CONVENIENT STORE Fire District: LATHROP <br />Q1. 00(es ❑ No Does your business handle a hazardous material in any guantlty at any one time in the <br />year? See the definition of hazardous material on page 2 of this form. <br />Yes o 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 questions in 01, please print, sign, and date the bottom of this form and return to the address above. <br />Q2. XYes ❑ No 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? 1 MONTH <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 r KNo 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 />I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br />Safety Code (HSC). I understand that if 1 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 or Authorized Agent: <br />Print Name: RAKHI CHAWLA Date: 10/24/2013 <br />Signature: K <br />Title: SECRATARY <br />