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R-a)W(b <br /> COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> Telephone(209)468-3420 <br /> FAX(209)468-3433 <br /> Website: www.sjgov.org/ehd <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business <br /> name and/or address in San Joaquin County is required. <br /> Business <br /> Name �AC�S LA CQC►L�Y� 1�� # �{ T� ( y <br /> Business Owner(s) t�`,/� /}� <br /> Name: (nf1 IUfUn� I Telephone: ill"I LI&Business <br /> Address: -79-10 VY • `lam S� • 0 Lt� �A ( " <br /> Mailingr <br /> Address(if different from �IO 2C�N �T r Q CA qS� <br /> ): l T kU1/ <br /> Nature of <br /> Business: ba �rGtl��' Fire District: (L V IZAL- <br /> Q1. p(Yes Oo Does your business handle a hazardous material in any quantity at any one time in the year? See the <br /> definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2. IDYes o Does your business handle a hazardous material, or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at any one time 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 applies to your business. <br /> OA. The hazardous materials handled by this business is contained solely in a consumer product, <br /> packaged for direct distribution to, and use by,the general public. <br /> IDB. This business is a health care facility (doctor, dentist, veterinary, etc.)and uses only medical <br /> gases. <br /> ❑C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes'XNo Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. DYes lo 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 forth and understand my requirements under Chapter 6.95 of the California Health and <br /> Safety Code. I understand that if I own a facility or property that is used by tenants, that 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. <br /> I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge. <br /> Owner or Authorized A re I91 <br /> X SDtL 6EI�QJ�A�U Date: Z— <br /> yy Pki�int Name <br /> X Title: 4V <br /> Signature ^-7 <br /> A <br /> S P �• 5 y -1 bio <br />