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SAN JOAQUiN Environmental Health Department COUNTY � ( E' OtrlESS yiOCvs iiFrc' . HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and /or address in San Joaquin County . Business Name : Aa 411 T �, c t r KA Telephone : Business Site Address : P1 SC ( p 1 ��^fi w• D Q� �Gl, ✓ 4�C Cit `� ✓ 3 Mailing Address ( if different from above ) : Business Owners ( ) Name : �i � G.h- 1 Telephone : Business Owner Address : C! (� Knc, ccuil D Pawt CoAl CogJ 33 -, Nature of Business : �VAM �( w. Fire District : Q1 . ❑ Yes 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 form . ❑ Yes , o 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 Flo Does your business handle an Acutely Hazardous Material ? See definition on page 2 . Q4 . ❑ Yes Is your business within 1 , 000 feet of the outer boundary of a school ? ( Grades 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 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 : 7 qS S Date : l I?(2l Zb23 7 Signature : Title : L � 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468 - 3420 1 F 209 464 - 0138 1 www . sjcehd . com