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SQN . l0AQU1N Environmental Health IDapartment <br /> ---C O i..J N T Y--- <br /> G ..a rn��s q ' ws herr- <br /> HAZARDOUS MATERIALS p�SCLOSURE SURVEY <br /> A separate survey form is required for each business name and/Or address in San Joaquin County. <br /> Business Nama: <br /> Tru by Hilton - Lodi Telepnone: <br /> Business she Adereas: 6'125 W Banner Street, Lodi, CA 95242 t �,p _ g62o_ <br /> 1-fn-' Irl F�RFhoNT FT STi'l('k'rt^ ^ <br /> Meiling Adareas pf mfrerant from above): e / . 'Z 6'7l A <br /> i 17 D�P T T�LS'f�E--Talepnon <br /> Business owner s)Nama: C.q — 4r. �-n 3 <br /> Q i T 6 T ^�'1 f k TO <br /> Baainesa owns.Aaarasa: 1 Fo-e olatrlcr. Woodbr dge Rural D stnct <br /> Nature Of Buslnas5: <br /> Hotel <br /> .... nflty at any one lima In<na yaar4 <br /> p1, o Yas m No Ooas your business handle a hazardous malarial'^e �, <br /> Sea the datinition of hazardous malarial on page 2 of this form tl ?(used oil,used <br /> Coes your business generate,treat,or store a hazartloua waste � . <br /> o Yea m No antifreeze,waste solvent,etc.) <br /> If your vnawar la"No^t0 both quaetlena In pt,Plwsa prinq at9n•end dela[ba bellem of[nla bYm and return to thv atltlresa abeva. <br /> o Vas o No Ooas your business nandgfaa hazardous materia1500a rounds.or0200ncubic fa t atany naetllme <br /> 02. n a quantity equal to or tar than 55 gallons, PO <br /> iin the yearn <br /> If•vee^.now long have you hentliatl these materials at Your buslnasa4 <br /> If"Yea",chacK any of[he following contlittons that apply to your business: <br /> o q Tha hazardous materials Handled by this business are contained splay in a consumer product <br /> packaged for direct distribution to and use by the general public. alsing or harvesting an <br /> o B. This business operates a farm for purposes of cultivating tna soil, r <br /> agricultural Or horticultural commotliy. <br /> p3_ o Ves m NO Coas your business handle an Acutely Hazardous Mated f a school?l(Griadas Kp29e 2 ' <br /> Qq. o Vas m No is Your business within 1.000 feat Of ine outer boundary O <br /> Y Or Pr s onsibilly t0 notiN the tenants Of the <br /> 1 nava reed the Information on this form and understand my requirements under Gnaptar 6.95 Offtop etlons 1a1 declare under tna <br /> C'iede amanta whl h rstU the mlatl prbr tof issuance OfpeC rtlfcata of OccuPan Y Ir b ginning <br /> raqui; gf par{ury that the infprmatbn provided on this tllaclosure survey is true and accureta[o the bast of my Knowledge. <br /> pane ty e v to submit your hazardous materiels Information. <br /> If you answered"Vas"to Ouasdon 2.please go online to--' , <br /> Owner Or Authorized Agent: T y I�� 7 <br /> 1 _ -I- 14.�� Oats: '� <br /> � Print Nama: <br /> 1' Title: <br /> ' Signature: <br /> 1668 E. Hazelton Avenues 1 <br /> BtocKton,CalYfomia 95205 1 T 209 468-3420 1 F 209 464-0136 1 www sjcehtl-corn <br />