Laserfiche WebLink
Mar.31.2017 10:18 AM <br />2092928113 <br />REC Mtb <br />MAR 31 2017 <br />San Joaquin County <br />Environmental Health DepartmeKPIPMW <br />a HEALTH <br />1868 E Hazelton Avenue "'-"'T <br />PROGRAM COORDINATORS <br />Stockton, California 95205 Robert MCClanon REHS <br />Jcff Canuesoo. RENS, REA <br />Kasey Foley, REHS <br />Website: WWW.Sjgov.org/elld Linda Turkalle, REHS <br />Phone: (209) 468.3420 Rodney Estrada, REHS <br />Fax: (209) 468-3433 Adrienne Easassser, REHS <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address In San Joaquin County. <br />Business Name; <br />Business Site Ad <br />Mailing Address (if different from above); <br />Business Owners) Name: <br />Business Owner Address: <br />Nature of Business: <br />Q1 <br />o Yea o No Does your business handle a hazardous material In any Ouardity at any one time in the <br />year? See the definition of hazardous material on page 2 of this form. <br />` Yee n No Does your business generate, treat, or store a hazardous waste 1M.ny auanOY7 (used oil, <br />used antifreeze, waste solvent, etc.) <br />It your answer Is "No"' to both questlons In 01, please print, sign, and date the bottom of this loan and return to tho address sbovo. <br />Q2, eyes o No Does your business handle a hazardous material, or a mixture containing a hazardous <br />material, In a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at <br />any one time in the year? 1_ <br />If "Yes", how long have you handled these materials at your business? qQ <br />If "Yes", check any of the following conditions that apply to your business: V <br />o A. The hazardous materials handled by this business are contained solely in a consumer <br />product packaged for direct distribution to and use by the general public. <br />013. This business operates a farm for purposse, of cultivating the sell, raising or harvesting an <br />agricultural or horticultural commodity. <br />03. ❑ Yes )No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br />04. ❑ Yes XNo Is your business within 1,000 feet of the outer boundary of a school? (Grades K•12) <br />I have read the Information on this form and understand my requirements under Chapter 5.95 of the California Health and <br />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 <br />tenants of the requirements which must be met prior to Issuance of a Certllloate of Occupancy or beginning of operations I <br />declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of <br />my knowledge. <br />Owner or Authorized Agent: <br />�M ' <br />4r.W W", <br />