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(RECEIV� <br />COUNTY OF SAN JOAQUIN OCT 12 2017 <br />OFFICE OF EMERGENCY SERVICES <br />2101 E. Earhart Avenue, Suite 300 ENVIRONMENT HEALTH <br />STOCKTON, CA 95202 <br />TELEPHONE (209) 953-6200 <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />Please read the information on the reverse side before completing this survey forth. A separate survey for each business name and/or <br />address in San Joaquin County is required. <br />Business Name: CVS plhaLrr(1" * 09261 Telephone: <br />Business Site Address: 100 W w41 AYenufC Wd] ) CA 95240 <br />Mailing Address (if different from above): <br />Business Owner(s) Name: CVS PhorMOL64 Telephone: <br />Business Owner Address: 1 CVS Dr1Ve, W00n40Ck i , RT 02995 <br />401 -"lbs- 160 <br />Nature of Business: Fire District: <br />QI. ❑Yes f�No Does your business handle a hazardous material in any quantity at any one time in the year? See the <br />definition of hazardous material on the back of this form. If your answer is "No", go to Question 4. <br />Q2. ❑Yes ®No Does your business handle a hazardous material, or a mixture containing a hazardous material, in a <br />quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time in the year? <br />If "Yes", how long have you handled these materials at your business? <br />If "Yes", check any of the following conditions that applies to your business? <br />❑ A. The hazardous materials handled by this business is contained solely in a consumer product packaged for <br />direct distribution to, and use by, the general public. <br />❑ B. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br />agricultural or horticultural commodity. <br />Q3. []Yes ®No Does your business handle an Acutely Hazardous Material? See definition on reverse side of this form <br />Q4. ®Yes ❑No 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 6.95 of the California Health and Safety <br />Code. 1 understand that if I own a facility or property that is used by tenants, that 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. t declare under the <br />penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br />Owner or Authorized Agent: <br />9176 �1'1 <br />✓ir.E Pdr4F.CAWA17— <br />(Rev 8/08) <br />