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0 0. 4 <br /> SAN .J o A Q U r N Environmental Health Department <br /> C•u I\I-r y---- <br /> HAZARDOUS <br /> -._._-HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County. <br /> French Camp Truck Terminal,LLC,a California <br /> Business Name: Limited Liability company Telephone: <br /> Business site Address: 17900 Murphy Parkway, Lathrop, CA 95330 <br /> Mailing Address(if different from above): <br /> Business Owner(s)Name:_Gurbinder Mangat Telephone: (408) 355-5700 <br /> Business owner Address: 17900 Murphy Parkway, Lathrop, CA 95330 <br /> Nature of Business: Truck trailer & trailer parking lot Fire District: French Camp McKinley <br /> Q1. n Yes E No Does your business handle a hazardous material in any quantity at any one time in the year? <br /> See the definition of hazardous material on page 2 of this form. <br /> o Yes e No Does your business generate,treat,or store a hazardous waste in any quantity?(used oil,used <br /> 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. n Yes n No Does your business handle a hazardous material,or a mixture containing a hazardous 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 /> n A. 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 purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. o Yes o No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4, ❑Yes c No 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 <br /> Code(HSC). I understand that if I own a facility or property that is used by tenants,it is my responsibility to notify 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 perjury 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.calepa,ca.gov to submit your hazardous materials information. <br /> Owner or Authorized Agent: <br /> Print Name: Gurbinder Mangat Date: f <br /> Signature: e»/f Title: Manager <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcelid.com <br />