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SU0014061
Environmental Health - Public
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SU0014061
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Last modified
4/27/2021 8:01:19 AM
Creation date
4/22/2021 9:48:34 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
RECORD_ID
SU0014061
PE
2635
FACILITY_NAME
PA-2100059
STREET_NUMBER
2750
Direction
E
STREET_NAME
ARCH
STREET_TYPE
RD
City
STOCKTON
APN
17726010, -14
ENTERED_DATE
4/12/2021 12:00:00 AM
SITE_LOCATION
2750 E ARCH RD
RECEIVED_DATE
4/19/2021 12:00:00 AM
P_LOCATION
99
P_DISTRICT
001
QC Status
Approved
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EHD - Public
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San Joaquin County <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />DIRECTOR Donna Heran, REHS <br />PROGRAM COORDINATORS Robert Mcclellon, REHS Jeff Carruesco, REHS, RDI Kasey Foley, REHS Linda Turkatte, REHS Rodney Estrada, REHS Adrienne Ellsaesser, REHS <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: _Cic::.:,ev::;..zk-�l�l .-;..u-=-'",__;S=-±o-!...z:..:J�c..--'-b=----=---==L;__;___;;_/.L ____ Telephone: S] O --U7-3 'tZ-'-fBusiness Site Address: _ull!IC..Z::.._8--=�:......::�:;.i.h�k-:::...al..:_: '='-....3<-l,s.L.+.IL..l.._-t!:__..'Za)�i,:__=---::�&...�k-_l""""'c,,,__C.,"'""'�_,.,._,, ___ C.=--A-----Cf-t--'t-b.__0_7 __ _ <br />Mailing Address (if different from above): __________________________ _ Business Owner(s) Name: Clo �""' Wh.:sk-�V\ Telephone: $]0 --U 7-3 Lf 2..':f Business Owner Address: ------------------------------------Nature of Business: �{��kk �zje>;'�f Fire District: vt1fZri tt:.:W� <br />Q1. o Yes 'fNo <br />□Yes �o <br />Does your business handle a hazardous material in any quantity at any one time in the year? See the definition of hazardous material on page 2 of this form. Does your business generate, treat, or store a hazardous waste in any quantity? (used oil, used antifreeze, waste solvent, etc.) 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. Q2. □ Yes WJo Does your business handle a hazardous material, or a mixture containing a hazardous material, in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time in the year? <br />Q3. Q4. <br />If "Yes", how long have you handled these materials at your business? _____ _ 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 product packaged for direct distribution to and use by the general public. □ B.This business operates a farm for purposes of cultivating the soil, raising or harvesting an agricultural or horticultural commodity. □Yes �oo Yes lfNo Does your business handle an Acutely Hazardous Material? See definition on page 2. Is your business within 1,000 feet of the outer-boundary of a school? (Grades K-12) <br />I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety Code (HSC). I understand that if I own a facility or property that is used by tenants, it is my responsibility to notify thetenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. Ideclare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best ofmy knowledge. <br />Owner or Authorized Agent: <br />PrintName: �k:s7 <br />Signature: � a Date: <br />0 <br />C) <br />\J'"J
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