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RECEIVED <br />FEB 1 7 2016 <br />ENVIRONMENTAL <br />HE!Tri n=APTAACKIT <br />Mailing Address (if different from <br />above): <br />Nature of <br />Business: Fire District: MY\ \-0A-k-rACA <br />COUNTY OF SAN JOAQUIN <br />Environmental Health Department <br />1868 E HazeIton Avenue <br />Stockton, California 95205 <br />Telephone (209) 468-3420 <br />FAX (209) 468-3433 <br />Website: www.sjgov.orgiehd <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: <br />Business Owner(s) <br />Name: S.QCk.C) <br /> <br />Telephone: v314_ <br /> <br />Business <br />Address: <br /> <br />CrD k.4 <br />\CS\ C-t,\J Q_6()‘ l'S‘fe\ &&4 r?Ck-‘14- • <br />01 41Yes ON° 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. DYes Eplo 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 200cubio 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 />tilA. 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 />DB. This business is a health care facility (doctor, dentist, veterinary, etc.) and uses oly medical <br />gases. <br />DC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br />agricultural or horticultural commodity. <br />03. DYes itlo Does your business handle an acutely hazardous material? See definition on reverse side of this <br />form. <br />Q4. DYes LINo 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 <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 />Own or Authorized A•ent: <br />X t -Q.. 0 • Date: <br />Title, <br /> <br />F/Applications <br />Page 4 of 6 <br />Signal <br />nriseffiando ncjApplications/Business License (Revised 02-24-15)