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FEB 22 2011 �V10fOFf4,RGf �ON7Y COUNTY OF SAN JOAQUIN NOV gp�''�_ t '9 OFFICE OF EMERGENCY SERVICES RONAtna.aimrrn8 r % ROOM 610,00=17II0USP. cooanrmTOn 222 I ASr WEBER AVENUE STOCKTON,CALIFORNIA 95202 TWEIP TONE(209)400.3962 HAZARDOUS MATJIUALS DIVISION(209)4683969 HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the information on the reverse side before completing this survey form- A separate survey for each business name andlor address in San Joaquin County is required. Business Name: Walgreens#10454 Walgreens CorporationTele hone: (209) 825-5481 Business Owner(s)Name: P Business Address: 1071 N. Main Street, Manteca, CA 95336 Mailing Address(if different from above): 3E Company, c/o Regulatory Department, 1905 Aston Ave,Carlsbad,CA 92008 Nature of Business: Drugstores&Proprietary Stores, Photo-finishing Laboratories Fire District Manteca Fire Department Q I. z❑Yes ❑No Does your business handle a hazardous material in any quantity at any one time in the year? Se:the definition of hazardous material on the bark of this form. If your answer is"No",go to Question 4. Q2. IYes� ONo fktcs your business handle a hazardous material,or a mixture containing a hazardous material,in a quantity equal to or greater than 55 gallons,500 pounds,or 200 cubic feet at any one time in the year? 'Refrigerant exempt, helium in quantities< 1,200 tuft. If"Yes",how long have you handled these materials at your business? N/A Il' "Yes",check any of the following conditions that applies to your business? p A. The hazardous materials handled by this business is contained solely in a consumer product packaged for direct distribution to,and use by,the general public. [3B, This business is a health care facility(doctor,dendst,veterinary,etc.)and uses hs,m(y medical gases. ❑C- This business operates a farm w purpnses of cultivating the soil.raising,or harvesting an agricultural or horticultural commodity. Q3- ❑Yea 17No Does your bucinccc handle an Acutely Harardmis Material? Sce definition On reverse side of this form. Q4. WYes ❑No Is your business within ISM flat of the Outer boundary of a school(grades K-12)? I have read the infonnation on this fume and understand my requirements under Chapter 6.95 of the California Health and Safety Code. I understand that if 1 own.a facility or property that is used by tenants,that it is my responsibility to notify the tenants of dho rc IklilnruenU whielr must Ix:met prior to issuaucc of a Ccrtirimte of Occupancy or beginning of operations. 1 declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge, Owncr or Authorized Agent: X Melissa LaBanc,Agent for Walgreens Corporation Date 01/10/2011 Print Name X r, 7Cj Title Regulatory Compliance Specialist,3E Company Signature (Rev 10196)