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;, SA� _'a:� �000{ .. �ryvircxr'errnran�. Y-4��x94h U�par4rrreuit <br /> c .r,,,,, �,.�ws t,drr,. <br /> HAZARDOUS MATERIALS OISCLOSU RE SURVEY <br /> A sap/a2ra�te survey form Is requir¢tl T�ojr ea/cn busin/e/ss name antl/or atltlrass in San Joaquin County. <br /> Business Name:�`//6 .J� /K�� �(��N�' �/� Telephone: ������i Zg/. ��� ��/ ' <br /> Business Site Atltlrass: —��0� �l /.J/J-tx//Z ���rsv:.r �� <br /> Mailing Atltlrass(iT tlifferent tro above): 9 1 <br /> Business Ownar(s) Name: / 0 Telephone: < Z-o 9'� 3��f- z�l Z <br /> Business Owner Atltl�jre,s�s: S/ �� l ����� �Z �l ��� 95��L <br /> Nature of Business:r/�1�� �' Fire Dislnct ��lJd-1����"L— <br /> Ol. v Yes Vo Does your business hantlle a hezartlous material in env vuaniity at any one time in the year9 <br /> SBe the definition of hezartlous mHterial on peg¢2 of this form. <br /> v Yes vnVO Does your business generate,treat,or store a hezartlous waste' t t '1(usetl oil,usetl <br /> antifreeae,waste solvent, etc.) <br /> 11 your answer Is"No^to both quastlens In D1,plaaea pFlnt.sigq and data lha bottom or this loan and return to[M1a atldreas above. <br /> 02. o Yes o No DOGS your busin055 hantllB a hezartlous material,or a miMure containing a hezartlous material, <br /> in a quantity equal to or greater than 55 gallons, 500 pountls.or 200 cubic Teei at any one time <br /> in the year? <br /> lT"Yes", how long have you hantlled these materials at your business'! <br /> If"Yes",check any of the following conditions that apply to your business: <br /> v A. The hazardous materials hantlletl by lhiS business are containetl solely In a consumer protluct <br /> packagetl for direct tllsVibution[O antl use by the general public. <br /> v B. This business operates a farm for purposes of cultivating the soil, rasing or harvesting an <br /> agricultural or hoMcultural commotlity. <br /> L73. o Ya5 o No Doas your business handle an Aoutaly Hazardous Matarial'l Sa®tlafini[iOn on page 2. <br /> 04. v V¢s v No is your business within 1.000 feet of the outer bountlary of a school9(O radar Kn 2) <br /> I have reatltha inform a[ion on this form antl UntlarstHntl my rBqulrem0nts untlar Chapt0r 6.95 of the California Healtn antl Safety <br /> Cotle(HSC). I untlerstantl that if 1 own a facility or property that is usetl 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. 1 declare under the <br /> penalty of perjury that the Information proyitletl on this disclosure survey is true and accurate to the best of my knowletlge. <br /> If you answeretl"Yes"to OUBStion 2, please go online to a na v to submit your hezartlous materials iMormation. <br /> OWnaf Of AVlhOriZatl Punt / <br /> Frint Name: ��UlN `-Ju/�-7�'7/cS�Y^) Date: z��L/Z-y <br /> �/9 /—Y <br /> Signature: <br /> rG !� �.gD-• Title: �TyS �'vr— <br /> 1868 E. Hazelton Avenue I StocKton, Calitomifl 95205 I T 209 4G8-3420 1 F 209 aG4-0138 1 wwwsjc¢M1d.com <br />