SU0015270 - Laserfiche WebLink

Home Browse Search

- ? 200251 SAN - , J Q A Q N I IV Environmentai Health Department 1 COUNTY Greatness grows Frere . HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and/or address in San Joaquin County , Business Name : ,Telephone : Business Site Address : ) I'w F. Mailing Address (if different from above ) : el'jr) Business Owner( s ) Name : . � ��-f &LCA 4 Telephone : �2u ( " -i' Business Owner Address : ) � t�PP (AO?5 a t� iii tr") , eiez��-� Nature of Business : 6A4D6LQk, ttj ' Fire District : 0.%gl Q1 . ❑ Yes XN 0 Does your business handle a hazardous material in any quantity at any one time in the year? See the definition of hazardous material on page 2 of this farm . ❑ Yes �(I'V0 Does your business generate , treat , or store a hazardous waste in any quantity? ( used oil , used antifreeze , waste solvent , etc . ) 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 . Q2 . ❑ Yes ❑ 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 : ❑ 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 . ❑ B . This business operates a farm for purposes of cultivating the soil , raising or harvesting an agricultural or horticultural commodity . Q3 . ❑ Yes ❑ No Does your business handle an Acutely Hazardous Material ? See definition on page 2 . Q4 . ❑ Yes ❑ No Is your business within 1 , 000 feet of the outer boundary of a school ? ( Grades K- 12 ) 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 . calepa . ca . gov to submit your hazardous materials information . Owner or Authorized Agent : Print Name : � C35 . Cjajol Date : C ?=A Signature : � Title : t_�� ' ' 1868 E . Hazelton Avenue Stockton , California 95205 1 T 209 468 -3420 F 209 464- 0138 1 www . sjcehd . com