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RECEIVED <br /> �A JAN 13 2011 <br /> OFFICE OFE AOUIN COOMy <br /> COUNTY OF SAN JOA.QUIN MERRFNC4'SE7RV0a <br /> OFFICE OF EMERGENCY SERVICES RoNALn a.n4LOwIN <br /> wa' ROOM 610,C)OURTIIOUSP. COORDINATOR <br /> 222 LiAsr WEBER AVENUE <br /> .a• ,rs .;v- STOCKTON,CALIFORNIA 95202 <br /> TnLOPHONE(209)469.3%1 <br /> HAZARDOUS MATERIA.1.S))IVISION(209).466-3969 <br /> HAZARDOUS MATERIALS DISCLOSUU SURVEY <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: Walgreens#10454 <br /> Business Owners)Nmme: Walgreens Corporation Telephone: (209) 825-5481 <br /> Business Address: <br /> 1071 N. Main Street, Manteca, CA 95336 <br /> — <br /> Mailing Address(if different from above): 3E Company,c/o Regulatory Department, 1905 Aston Ave, Carlsbad,CA 92008 <br /> p <br /> Nature of Easiness: <br /> Drugstores& Proprietary Stores, Photo-finishing Laboratories Fire District: Manteca Fire Department <br /> Ql. R❑Yes ❑No Does your business handle a hazardous material In any quantity at any one time in the year? See the <br /> definition of hazarduus material on the back of this form. If your answer is"No",go to Question 4. <br /> Q2. ,<❑Yes' ONO rxics 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 /> "Refrigerant exempt, helium in quantities< 1,200 cuff. N/A <br /> If"Yo",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 /> p A- ?'Ile hazardous malciials 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 is a health care facility(doctor,dentist,veterinary,etc.)and Uses qq(y medical gases. <br /> ❑C- This business operates a farm for porpmas of cultivating the soil,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yea [flKo Does your busincas handle an Acutely Havardmis Material? See definition on reverse side of this Foran. <br /> Q4. Dyes pNo 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 font 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 <br /> (Inc Iuµlirotucros which a ml Is; net prior to issuance of a Certificate of Oeeupamy 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 Melissa LaBanc,Agent for Walgreens Corporation Date 01/10/2011 <br /> m <br /> Print Nae <br /> 7C Title Regulatory Compliance Specialist,3E Company <br /> Signature (Rev 10196) <br />