Laserfiche WebLink
u1 � San Joaquin County <br /> 0.q . . ' DIRECTORQ Environmental Health Dlepartument Donna Heran, REHS <br /> 1868 E t#azettan Memo PROGRAM COORDINATORS <br /> Stockton , California 95205 Robert McClellon, REHS <br /> Jeff Carruesco, REHS, RDI <br /> Kas <br /> � LIFc, �� Website: wwwzjtgoYLinda inda Foley, REHS <br /> Linda Turkatte, RENS <br /> Phones (209) 46€#-3420 Rodney Extra H5 <br /> IF= (209) 468-3433Val <br /> Adrienne Ells ;n <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY k:NV/Rp <br /> A separate survey form is required for each business name and/or address in San Joaquin County. �`1 ��Nr <br /> n P RMrrr���t%iH EA� res <br /> Business Name : &u.1 is � �A yVlo}'i ,e 12uz, ? AJ r Telephone: <br /> Business Site Address: �} t-�t !t l ✓1 ist �-GY C � 9 S'� � � 0 <br /> Mailing Address (if different from above): f C' , ,� <br /> Business Owner(s) Name. �.� Telephone: <br /> 1 , o <br /> Business Owner Address: Y , O ( Dcg:�)Y� <br /> Nature of Business: t x r43 \�ZPc 9 c6ir Fire District: <br /> Q1 . Yes ❑ No Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on page 2 of this form . <br /> <4 Yes ❑ No 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 Q1 , please print, sign, and date the bottom of this form and return to the address above. <br /> Q2. Yes o 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? wh De*Wh1 <br /> if "Yes", check any of the following conditions that apply to your business : <br /> o 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 )eNo !lees your business handle an Acutely Hazardous Material? See definition on page 2 . <br /> Q4.. ❑ Yes ',IVa Is yourbusiness within 1 ,000 feet of the outer boundary of a school? (Grades KA2) <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 (NSC) . I understand that if I 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: E cx,r L� 1 %T" I Date: <br /> Signature: 4ee Title : 0 U0 ht v' <br /> 1 <br /> Revised 11107172 <br />