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SAN JOAQUIN Environmental Health Department COUNTY - ____.v_ HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and /or address in San Joaquin County, Business Name : George Perry and Sons , Inc . Telephone : 209 - 249 - 2400 Business Site Address : 13881 S Highway 99 , Manteca , CA 95336 Mailing Address ( if different from above ) ; PO Box 2588 , Manteca , CA 95336 Business Owner( s ) Name : Ron Perry Tele hone : 209 249 - 2400 p Business Owner Address : P. O . Box 2588 , Manteca , Ca 95336 Nature of Business : Fruit stand Fire District : Lathrop /Manteca Q1 . a Yes ❑ No 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 N No Does your business generate , treat, or store a hazardous waste in any 4uantityr? ( 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 A 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 . Be This business operates a farm for purposes of cultivating the soil , raising or harvesting an agricultural or horticultural commodity. Q3 . ❑ Yes XNo Does your business handle an Acutely Hazardous Material ? See definition on page 2 . Q4 . c Yes X 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 5 . 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 . cale a . ca . ov to submit your hazardous materials information . Owner or Authorized Agent : Print Name : � ^� / Date : V ' / z � a o Signature : Title : C ? O Levee cmmom 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 458-3420 1 F 209 464-0138 1 www . Sicehd . com