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p��000102 <br /> SAN �:JOAQUIN Environmental Health Department <br /> I 1 i �- '1 GOUNTY <br /> �.. <br /> / Greq zn ass grows /,ora. <br /> HAZARDOUS MATE REALS O�SCLOSU RE SURVEY - <br /> A s�para``t�`survey form is required for each business name and/or address in San Joaquin County. p _ <br /> Business Name: CN\LAS ��.- _._�O`tf'� Telephone: o��l- 3�J�'\ � � 1I <br /> easlnesa sue Atlareaa: 92i,a.6 \JJcST !\cv�t� \2 Lt�.� ` Com . �L pS La�d2 <br /> Mailing Address(If different fromOa�bov�): P.�. Q(lll a�3� L-OU 1. C� l U,.�'` <br /> Business Owners)Name: �P�.it.- � � \�b.�e\ �_ TalepM1one �C�'i - 33 V-SCl\ I <br /> easiness owner Adaress: 1`-\\C. A.-u v.�_ L 1_«�.. C'� L1SoZ�-la/� <br /> Na[ura of Business:�"� Fire District: �dG� IAPI �L� -tc L JAG QI S� <br /> Q1. o Yas o No Doas your business hantlla a hazartlous material in antiN at any one rima in the year? I <br /> Sea Ma tlaini[ion of hazartlous mataMal on page 2 of this form. <br /> o Yes o No Doas your buslnass generate,[res[,or stare a hazartlous waste in env quant N?(used oil,used <br /> antifreeze,waste solvent,etc.) <br /> If your annwar I//s"N o"to botM1 quna<iona In 02,please prinq alga and data the bottom W tM1la Torrrl and return to the atldresa above. <br /> Q2. pYBs v No Does your buslnass ttantlla a hazartlous motorial,or a miMura containing a hazartlous material, <br />' in a quantity equal to qr greater than 55 gallons.500 pounds.or 200 cubic feat a[any ono Uma <br /> in the year? <br /> If"Yas",how long have you handled these materials at your business? X0.3 ty�l �"S <br /> If"Yas",check any of[ha Following conditions that apply[o your buainass: 0 <br /> v A. Ther hazartlous materials handled by this business ora contained solely in a consumer product <br /> packaged for direct distribution to and use by the general public. els n <br /> This business operates a farm for purposes of cultivating the soil. r ing or harvesting a <br /> agricultural or horticultural commodity. <br /> Q3, o Yes b N//o Doas your buslnass hantlla an Acutely Hazardous Material? Sae definition on pogo 2. <br /> Q4. o Vas envo Is your buslnass within'1.000 Teet of the outer boundary of a school?(Grades k-t 2) <br /> I have read the Informatlon on this form and understand my raquiremants antler Chapter 6.95 of the California Health and Safety <br /> Cotler(HSC). I understand that if 1 own a facility or property that is used by tananis,It is my responsibility to no[iry the tenants of the <br /> raquireman5 which must be met prior to is of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of pa jury that the information provided on this disclosure survey fa true and accurate to Me bass of my Knowledge. <br /> If you anawaratl"Yas"[o Question 2,please go online to cess caleoa c v to submit your hazardous materials information. <br /> Owner or Authodzatl Agent <br /> Print Nama: � Data: �o - \ �- �4 a d <br /> Signature: TI[la: �-- ,. - ���U <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0'138 www.sjcehd.com <br />