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SANJOAQUIii Environment.. Health Department <br /> COUNTY <br /> Greatness arows . 2000 <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: _Telephone: (� <br /> Business Site Address: " <br /> Mailing Address(if different from above): ��—�� �?��"�� \..•�'j"«-`C��� �� ��+ <br /> Business Owner(s)Name: Telephone: <br /> Business Owner Address: <br /> Nature of Business: "�� C�— ���^ Fire District: <br /> Q1. ❑Yes V 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 /> ❑Yes talo 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. u Yes R+IQo 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 /> Ve 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 /> This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes 1SNDoes your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. o Yes _CS4o 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 /> CPrint <br /> - � A- <br /> Signature: Title: <br /> � <br /> 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br />