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SAN&l �� � � ` � �� ~ 0 Health �� r�mm � <br /> ��� �� 'J � �Q� � �� �~���U���������u x o��x�no Department <br /> ----C } JNT\---- <br /> G/eotnegrow6erc. <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Aseparate survey form is required for each business name and/or uddnesainSonJoaquinCounty. <br /> i <br /> Lucky Fl�O| 7-n/r�/T��3'|2� ��E\��'�O �O�-��1����(l1 <br /> Business Name: ~~ ' Truck/Trailer^ Parking� To�phono ^-~~ ~^- ' ~~~ ' <br /> STATE ROUTE EAST FRONTAGE ROAD, 8TD{�K3ON CA. A�PN 1��172-54 &55\ <br /> 8uoinoaaSdaAddmeo� ` ' <br /> �71� FlF)`�| �� /�/�U�T T��(��� ��/\ ���7�7 <br /> �ai|ingAddnaoa(�d�een\hnmabovo)� ^-' '^- ^~^~ ' �^- COURT,' ' ' ' ~ ``~ ' ^~' `' ~~~' ' <br /> GOLDEN PFUK�E INVESTMENTS, LL� �O�-��1-��O1 <br /> 8ua�000 ��no�o) Nomo� Telephone: ^-~~ ~^- ' ~~~ ' <br /> Business Owner Address: 2712 ~OYL - COURT' TRACY C4~ 95377 <br /> T�U��� / TRAILER ����|��� ' MONTEZUMAF|RE DISTRICT <br /> Na�vaofBm�noon ' ' ^^~^^' ^ ' ' ' ~ ^'�^-' ^ ' ' ^' ~ ~' `^~ Fire District: <br /> 01. oYoo kNo Does your business handle uhazardous material in anV quantit/atany one time inthe year? <br /> See the definition ofhazardous material onpage 2ofthis form. <br /> oYes c<No Does your business generate,treat,orstore ohazardous 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 /> 02. oYos 44No Does your business handle ahazardous m�oho|.urumixtumcontaining ahazardous m�eha|. <br /> ^` inaquantity equal toorgreater than 55gallons,50Upounds,or20Ocubic feet atany one time <br /> inthe year? <br /> )f"Yeo . how long have you hund|od.theaomaterials atyour business? <br /> |f~/oe . check any ofthe following conditions that apply toyour business: <br /> Li A. The hazardous materials handled by this business are contained solely in a consumer product <br /> packaged for direct distribution boand use bythe general public, <br /> I <br /> o B. This business operates a farm for purposes of cultivating the ooU, raising or harvesting an <br /> agricultural orhorticultural commodity. <br /> Q3. oYoa EiNo Does your business handle anAcutely Hazardous Material? See definition onpage 2. <br /> �� <br /> O4. mYoo ���o 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 mot prior to issuance of Certificate of Occupancy or beginning of operations. | 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 /> |fyou answered ''Yon''toQuestion 2. please goonline to tosubmit your hazardous materials information. <br /> Owner orAuthorized Agent: <br /> Print N oto: <br /> SignatureTitle: <br />