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� � &U | � & ��8K� <br /> ����[� �����W ��� <br /> C.OUN [ Y <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Aseparate survey form is required for each business name and/or address inSan Joaquin County. <br /> ly�c��� 14 LLC 484-���-���� <br /> 8uo�eoallome� ` ^-~'` ' ^�~ Telephone: �~ ' ����_______ <br /> 5550 E. (��2�8�8B ��O'�� ��tO�L��� �4 ����1� <br /> BuoineooGih�Addnasu� _ ' — '^ Road,` `^^ ~^^ ^ ~ '— <br /> Ma ngAddneso(ifdifferenthomabove): 1801 Market Street, Suite 2701, Philadelphia PA 19103_ <br /> ^�����| 1^1 | �� ��8^�-5��-����� <br /> BusineooOwnm{a1Noma_ ~-�^ �^^^ Telephone: ~ ~- <br /> 801 K8�����t ���[2�� ��i�t� �7�1 �o������h�hi� PA 1��03 <br /> Buo\nessOwnerAddrass� ' Market ' ^~ ' Philadelphia ~ ` <br /> [�n��[ ��fnraWaterloo-��onado <br /> Na�reoyBuoineso� F)ne[�u��ct <br /> Q1. RiYo* oNo Does your business handle ahazardous material in any quantity o(any one time|nthe year? <br /> See the definition ofhazardous material onpage 2ofthis form. <br /> oYea wNo Does your business generate,treat,orstore ahazardous waste kn any quantity?(used oil,used <br /> antifreeze,waste solvent,e{c.) <br /> If your answer Is"No"to both questions in Q1,please pfln�sign,and date the bottom of this form and return mthe address above. <br /> O2. sYeo oNu Does your business handle a hazardous material,or a mixture containing a hazardous material, <br /> inaquantity equal\oorgreater than 55gallons,5OOpounds,cv2OOcubic feet atany one time <br /> inthe year? <br /> 3 years <br /> |f~Yeo^.how long have you handled these materials otyour business? __�__________ <br /> |f^Yes^.check any ofthe following conditions that apply toyour buaioaoo� <br /> EiA. The hazardous materials handled by this business are contained solely in a consumer product <br /> packaged for direct distribution\oand use bythe general public, <br /> oB. This business operates a farm for purposes of cultivating the ooU, raising or-harvesting on <br /> agricultural orhorticultural commodity. <br /> O3. oYev (9 No Does your business handle anAcutely Hazardous Material? See definition onpage 2 <br /> CN. oYes sNo |oyour business within 1.00Ofeet mfthe outer boundary ofoschool?(Grades K-1c} <br /> I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health d Safety <br /> Code(HSC). |understand that if|own afacility orproperty\hatisuaadby1enantsit is my responsibilityionotify the tenants of the <br /> requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations, I declare under the <br /> penalty of peoury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> If you answered'Yes'to Question 2, please go online to cers.f-aier)a c,3gov tosubmit your hazardous materials information. <br /> Owner orAuthorized Agent: <br /> Print Name: � <br /> UCL V1 V1 C~ �/(^ / (l�� <br />