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• p► artment SANJOAQUIN Environ meatal health Re l) fct72 :ttSS , IC : : C iere HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and/or address in San Joaquin County . Ir Business Name: t` ) P p (,� - �, r�r7 7 � h Tele hone: Business Site Address , � 1 A)a Al Mailing Address (if different from above) : Business Owner(s) Name : 0 Telephone ; Business Owner Address : 7 (, Ch 1 Nature of Business : *VPA ) C. V - EAELj i t � t Fire District: te l " Q1 . o Yes VN o Does your business handle a hazardous material in anyquantity at any one time in the year? See the definition of hazardous material on page 2 of this form . o Yes A0 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 01 , please print, sign, cmd date the bottom of this form and return to the address above . 4o ' Q2. o Yes d 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 . o B . This business operates a farm for purposes of cultivating the soil , raising or harvesting an agricultural or horticultural commodity . 61 Q3 . o Yes 5/N o Does your business handle an Acutely Hazardous Material ? Secy definition ars page 2 . Q4 , o Yes o No Is your business within 1 , 060 feet of tie outer boundary of a school? (GM- des 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 oven a facility or property that Is used by tenants , It is my responsibility to notify the tenants of the req , � r .,.x. } Eir�h *n !ass_ h met nrinr to csraar� re of a t ; erficate of Occupancy or beginning of operations . ! declare candor the penalty of perjury that the irrformat'ron provided on this disclosure sur<pey is tree and aerate to the best of my knot&Ac. rd if you answered "Yes" to Question 2 , please go online to E!E,!rs .calGc� Ica ,gov to submit your hazardous materials information . Owner or Authorized Agent: owlll 04 Print Marne : yc €? ,, pate : - ' Signature : Title : j07L 1868 E . I-1 ! zelton Avenue ►, Stockton , California 95205 � T 209 468 - 34. 20 � F 209 464-0138 � vPAr ✓ . sjcehd . carn