Laserfiche WebLink
pquib, Ifa +IP <br /> IVED <br /> L' 1� 04 001 lk� 0 <br /> APR 12 2004 <br /> COUNTY OF SAN JOAQUIN <br /> "EA;EfiGENCY SERVICE <br /> OFFICE OF EMERGENCY SERVICES <br /> Room 610, Courthouse <br /> 222 East Weber Avenue <br /> Stockton, California 95202 <br /> Telephone (209) 468-3962 <br /> Hazardous Materials Division (209) 468-3969 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business name and/or <br /> address in San Joaquin County is required. <br /> Business Name: Crystal Valley Cellars , LLC <br /> Business Owner(s)Name.Cosent ino Signature EnterpriseMlephone: (707 ) 944-1220 <br /> Business Address: 16750 E . State Highway 88 , Lockeford , CA 95237 <br /> Mailing Address(if different from above): 7415 St . Helena Highway , Yountville , CA 94599 <br /> Nature of Business: Winery Fire District.' Clements <br /> me in the <br /> Ql. 17Yes LXtJo yoes your <br /> Seethe definition le a hazardous material in any quantity at any o <br /> of hazardous material on the back of his form. if yne our er? answer is <br /> No,"go to Question 4. <br /> xture <br /> ous <br /> Q2. OYes O No Does material In a quantity equal to or business handle a r greater than 55 gallons,zarrious material, or a i500 pounds, or 200cbiicfeet at <br /> anyone 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 /> 0A. 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 /> OB. This business is a health care facility(doctor, dentist, veterinary, etc.)and uses only medical gases. <br /> t7C. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br /> horticultural commodity. <br /> Q3. OYes ONo Does your business handle an acutely hazardous material? See definition on reverse <br /> side of this form. <br /> Q4. t7Yes hNo 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 Code. <br /> I understand that if I own a facility orproperty that is used by tenants, that it is my responftility to notify the tenants of the requirements <br /> which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury <br /> that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent., <br /> X Julie Weinstock , Vice Pres . e: 3/ 11 /04 <br /> Pr nt Nam <br /> r :ip Title: Vice President Operations <br /> Sionature <br />