SU0015355 - Laserfiche WebLink

Home Browse Search

hr,onw c SAN%IGA U I N Environmental Health Ilepartment �COUN`fY-- c ; *¢.� Greatness grows her,, HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each bQsln4ss trams andfor address In San Joaquin County. Business flame: l � Telephone: guslness site Address: f t ] V . 4 Malling Address(If dlff4rertt from above): Business owner(s)Name: r✓t7t.�� ,� ~" -- J—rnt—.,fit ,Tsiaphone: Bualneas OwnorAddreas: rn , Nature or Business: "s+g File Olsltfct CIL ❑Yes �ff la Does your business handle a hazardous material J.[LM tggantliv at any one time In the year? See the definition of hazardous material on page 2 of this form. ❑Yes yNo floes your business generate,treat,or store a hazardous waste b anvglrankltv7(used oil,used antifreeze,waste-solvent,sic.) lryaw bnswor Is"No"to both quesNone In Qt,pleas print,elgn,and data the bottom of thle form and return to the eddraw above, 42• o Yes ❑No Does your business handle a hazardous matedal,ora mlAura contalning s hazardous matOrial, In a quantity equal to or greater than 66 gallons,500 pounds,or 248 cubic fest at any ant Irma In the year? If"Yes",how long have you handled these meterlats at your business? If"Yes",check any of the following condlllons that apply to your business: L)A. The hazardous materials handled by this business are contained solely In a consumer product packaged for direct dletributton to and use by the general public, ❑a. This business operates a farm for purpose Of cultivating the Goll, raising or harvasling an agricultural or horticuitural commodity. Q3. ❑Yes ❑No Does your business handle an Acutely Hazardous Material? See definition an page 2. 04. o Yes a No Is your business wilhlo 1,400 feet of the outer boundary of a school?(Grades K-12) I have read(he Informallorh on this form and understand my rsqulrements Under Chapter G.95 of the California Has Ith and Safety Cada(HSC). I understand that If I own a facility or property that Is used by tenants,It Is my responslblllty to notify the tenants of the requirements which must be met prior to Issuance of a Certificate of Dccupanoy or beginning of opotatlons. I declare udder the penally of pe jury 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,pleaaa go onllne la MM pig ena4a,aov to submit your hazardous materials Information. Owner or Authorized Agent: Print Name: YA 0A G,W- Dai: ter' g /a Signature: (3 1888 rm.Hazelton Avenue I Stockton,California 95208 1 T 209 488.3420 I F 209 464-D138 I WWW,Slcehd.com PA2300005 Scanned with CamScanner