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PA 20.0 0.17 9 <br /> SAN JOAOUIN Environmental Health Department <br /> .......C0UN'l­y------- <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or addres9 in S a n Joaquin County, <br /> Business Name: Orlando's Market <br /> Telephone: 916-708-499.9 <br /> Business Site Address: 18754 Highway 26, Linden, CA 95236 <br /> Mailing Address(if different f*rprn above): <br /> PO BOX 1500, Linden, CA �952.36 <br /> Business Owner(s)Name: Sam Orlando 916-708-4999 <br /> Telephone: <br /> Business Owner Address: 1-10.Box 1500, Linden, CA 95936 <br /> Nature of Business: Outdoor Patio Fire District: Linden-Peters <br /> Q1. n Yes x No Does your b--siness handle a hazardous material in a uantit at any one time in the year? <br /> See the definition of hazardous material On page 2 of this.form, <br /> Yes. x No Doesyour business generate,treat,or store hazardous waste Lgany.guano ?(used oil,used <br /> antifreeze,waste solvent,etc.) <br /> If your answer is"bio"to both cluestions In Q1,please print,sign,and date the bottom of this form and return to the Address above: <br /> Q2. c Yes s No Does your business handle a hazardous.material,Ora mixture:containing a h <br /> .azardous material, <br /> in a quantity equal to or greater than 55:gallons,*500 pounds,or 200 cubic feet.at any one time <br /> in the year? <br /> if"Yes.',.how long have you handled these materials at your business? <br /> If"Yes",check any of the following conditions that apply to your business; <br /> The hazardous materials handled by this business are contained solely in,a consumer product <br /> packaged for direct distribution to,and use by the general public. <br /> B. This business operates a farm for pu*1*006. 0s of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity.. <br /> Q3. Yes No Does your business handle an Acutely:Hazardous Material? See-definition on page 2. <br /> 04. U Yes ^No Is your busine.s5within 1,000feet 6f the Outer bou Wary of a school?(Grades K-12) <br /> I have read the information.on this form anal.understand.my requirements under Chapter 6.95 of the CaliforniaCode(HSC). I understand Health and:Safety <br /> 1hatifl own afacilityorprop�ertytha'tls used by tenants,itis rhyre-sporisibility10 notify the tenants of7the <br /> requirements which must be met prior to issua.1ce of-9 Certificate.of Occupancy or beginning of operations. I declare under the <br /> penalty Of perjury that the information provided on this disclosure su rvey is.true and accurate'to,the best of my knowledge. <br /> If you answered'Yes"to Question 2,please,go Online to ge--mcalepa cagov to submit your hazardous materials information. <br /> Owner or Authorized Aqont: <br /> Print Name. <br /> Signature: <br /> 1866 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-01.38 1 www.sjcehd.com <br />