Laserfiche WebLink
PIA220024 7 <br />' SANAOAQUIN Environmental Health Department <br />tW 161 COUNTY <br />C,ICIF°Greatness grows here. <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: <br />Wodbridge Partners, Inc. c/o Jeff Crothers Telephone: 209-986-4150 <br />Business Site Address: 18846 St. Rt. 99 E. Frontage Road, ACampo, CA <br />Mailing Address (if different from above): 119 E. Weber Avenue, Stockton, CA 95202 <br />Business Owner(s) Name: Jeff CrotherS Telephone: <br />Business Owner Address: 119 E. Weber Avenue, Stockton, CA <br />Nature of Business. Truck Parking <br />(209) 986-4150 <br />95202 <br />Fire District: Woodbridge <br />Q1. u Yes o No Does your business handle a hazardous material in any quantity at any one time in the year? <br />See the definition of hazardous material on page 2 of this form. <br />D Yes o No Does your business generate, treat, or store a hazardous 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. u Yes o No Does your business handle a hazardous material, or a mixture containing a hazardous material, <br />in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time <br />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 apply to your business: <br />u A. The hazardous materials handled by this business are contained solely in a consumer product <br />packaged for direct distribution to and use by the general public. <br />❑ B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. ❑ Yes ❑ No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />Q4. o Yes o No 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 met prior to issuance of a Certificate of Occupancy or beginning of operations. I 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 />If you answered "Yes" to Question 2, please go online to cers.calepa.ca.gov to submit your hazardous materials information. <br />Owner or <br />Print Na <br />Signature <br />Authorized Ag J l <br />Nam �,61 Date: <br />Title: <br />1868 E. Hazelton Avenue I Stockton California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />