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PA22UO14a ° rw SHAWN N Environmental Health Department -•—COUNT Y--- Gretrtrress gre ws here. HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey%rm is requited 5or eadn business name andtor address in Sdn 3aaquin County. Business Name: Tru by Hilton - Lodi TetephnnQ: Business site Address: 6125 W Banner Street, Lodi, CA 95242 Mailing Address(if different from above): } W OWE EN o )1 !oC, .__.... .... Business Owner(s)Name: 1.,11 �� .'� -TTI—ALL 1 -Telephone: Business Owner Address: 1 -7o 7 Fi2 c- r A o i\i T 6 1 ,s imc k"["b N C A ^ q5�aC) 3 Nature at Business: Hotel Fire District- Woodbridge Rural District . fli. n Yes Y,No Does your business Nandi_,a Nazasdotus mallay%i in anyguanttity at any one timt in tNs year? See the definition of hazardous material on page 2 of this form. ❑Yes Q No Does your business generate,treat,or store a-hazardous waste in any ouantitx?(used oil,used antifreeze,waste solvent,etc.) 5S your answer%%"tto"to blAh gmrsyoms in Q'S,pkftSe pVWA,sem,and date*ie bottom of Wa tosm and retuwn to lht-addreuss abaft. Q2. ❑Yes a No 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? 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: 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. dB. This business operates a farm for purposes of cultivating the soil, raising or harvesting an agricultural or horticultural commodity. 03. ❑Yes a No Does your business handle an Acutely Hazardous Material? See definition on page 2. Q4. ❑Yes o No Is your business within 1,000 feet of the outer boundary of a school?(Grades K-12) 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 the tenants of the- requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. If you answered`Yes"to Question 2,please go online to cers.caleaa.ca.aov to submit your hazardous materials information. Owner or Authorized Agent: } ) Print Name:- C �1�� cf e-1 Date: r Signature: Title: 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com