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,0Lg3� <br />COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES RONALD E. BALDWIN <br />Q`;T <br />( � Room 610, Courthouse <br />� L.� TOR OF <br />REC <br />a: E � � E b 222 East Weber Avenue Y OPERATIONS <br />V <br />•:c:• PProval of la <br />Stockton, California 9520 e; mit or an a s Shall not be construed to be a <br />SEP 0 9 2016 Telephone (209) 468-39 coon of the San J o�Val of any violation of any <br />-� s.�u..� in C unty Codes of Ordinances. <br />ENVIRONMENTAL HEALIH"azardous Materials Division (209) 468-3969 <br />Sinner, I <br />PERMIT/SERVICES <br />HAZARDOUS MATERIALS DISCLOS�VE <br />,OLIN BUILDING INSPEC710, DEPT. <br />Please read the information on the reverse side before completing this survey form. A separate survey for each business name <br />and/or address in San Joaquin County is required. <br />Business Name: Goldstone Land LLC, dba Bear Creek Winery —GO <br />P- Y31 3 <br />1(7 <br />Business Owner(s) Name: TTlej ne: <br />Business Address: 11900 N . Furry Rd . , Lodb61N MF DP I ANS SHALL <br />Mailing Address (if different from above): <br />Nature of Business: W inery <br />Q I .)(Yes <br />BE ON JOBSITF_ OR NO <br />REQU EST�•�; tS Ff> 1-4QW S <br />ONO Does your business handle a hazardous material in any quantity if any on1 Ie time n'th y az'See the definition <br />of hazardous material on the back of this form. If your answer is No," go to Question 4. <br />Q2.Yes ONO Does your business handle a hazardous material, or a5mFiE-E containing kNizardousmaFeQ l n as ,qi uantity <br />equal to or greater than 55 gallons, 500 pounds, or 200cubic feet at any one time in the year? <br />If "Yes," how long have you handled these materials at your business? decades <br />If "Yes," check any of the following conditions that applies to your business. <br />OA. The hazardous materials handled by this business is contained solely in a consumer product, packaged for direct <br />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 />OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br />horticultural commodity. <br />Q3.xves ONO Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br />Q4. OYes Ao 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. I 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. I 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 />X Craig Rous Date: <br />P Name Director Of Operations <br />g Title: <br />Signature <br />F:\Devsys\Planning Application Forms Page 1 of 2 <br />Hazardous Materials Disclosure Survey (Revised 8-25-03) <br />