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pavtmr <br />SAK-JOADUM <br />It Environmental Health De <br />%�, a <br />0 U N T Y <br />4 <br />reotness 9rotys here, <br />HAZARDOUSMATERIALSDISCLOSURE SURVEY <br />A separate surveyform is required for each businessname. andlor address In San Joaquin County, <br />Business Name: Loc4aford MaterialsTelep I hone: 109-3294411 <br />Business Site Address: P0:B0X,9W Lookeford.Cat)5237 <br />Mailing. Address (if different from a0eve). PO Box 980 Loi3keford Ca 96237, <br />Business Owners) Name* <br />Jesus Men 209.329-1412 <br />Telephone: <br />Business Owner Address - <br />PO BOX 980 Loekeford Ca 96237 <br />Nature Of Business: Locketo rd Met er lals Fire District: Stockton <br />011: qpfesos <br />40 <br />Debuhandle dot4faliquantity tany one tirrie. In the year? <br />yoursinesshah�e-a azarus material any a <br />See the definition Of hazardous material on page 2 of this form. <br />0 Yes V/0 <br />Does your business generate, treat, orstore:a hazardoues waste 4n anyguantity? (used oil, used <br />antifreeze, w* asta solvent, etc.) <br />If your answer is "NoP to both questidna: In.01 pfeaseprintj sign, A date the boftorolofthis Iorm-and:return to the address above.. <br />02. 1301 uNo <br />ah o <br />Does:your business handlO.a ha, hazardousmaterial; <br />In, a quant , ity equal to or greater than 55 gal .1 lons, 500 poundsior 200 cubic feet at any one time <br />in the year? <br />If "Yes", how long have you handed these materials at your business. N/A this is a new business. <br />If *Yesof check any of the following conditions hat apply to your business: <br />o A, <br />The hazard6us materials handled by this business are contained solely in a consumer product <br />packaged for direct distilibution to and use by the general public. <br />08. <br />This business oprates a; farm for purposes of cultivating the -soil, raising or harvesting at! <br />ageicultural'orhorticultural oonim <br />.03. r yes, o <br />Does your buMness handle an Acutely HazaMous Material? See definition on page 2. <br />Q4. a Yes � -VANo <br />Is your business within 1,000 feet of the outer boundary of a school? (Grades K-12) <br />have read the information on this form and understand.my requirements under Chapter 6AS of the: California Health and, Safety <br />-Code, (HSC),- I understand. that If I dft:a -facility or property that is used by tenants, itis. my responsibility.to notify the tenants of the <br />'requirements which must. be, met prior to issuance of Certificate of. Occupancy or beginning of opera.fions, I declare under the <br />penalty of perjury that the InforniAtion.provided on this discloSuresurvey is true and a0cu-tate, to the best of my knowledge. <br />If you answered "Yes" to Question Z please go online to :cers.calepa.ca.gov tosubmit your hazardous materials information. <br />Owner or Authorized -Agent <br />Print Name,.. JesusVeza ate: 8131/2020 <br />Signature: -rifle- <br />nature,. <br />f <br />18.69 E,:Hazeken Avenue I Stockton, California 95205 1 T 203 468-34201 F 209 464-0138 1 www.sjc.eht.com <br />