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RECEIVE® JAN 112010 SAN JOAOUIN COUNTY OFFICE OF EMERGENCY SERVICES hoq!h COUNTY OF SAN JOAQUIN r •py OFFICE OF EMERGENCY SERVICES RONALn r.nALIOM ROOM 610,CAUR•t'110S15P. t ' tl 222 BAST WEBER AVENUE °a• : SToCK1'ON,CALIFORNIA 95202 Tf3Lt KONe(209)46113962 I� NA7AP.D0US MATFRL4.0 AIVISiON(109)468-3969 L 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 Business Owner(s)Name: Walgreens Corporation Telephone: (209) 825-5481 Business Address: 1071 N Main Street, Manteca, CA, 95336 Mailing Address(if different from above): 3E Company,do Regulatory Department, 1905 Aston Ave, Carlsbad,CA 92008 p Nature of Business: Drugstores&Proprietary Stores, Photo-finishing Laboratories lire District: Manteca Fire Department Q 1. pYes ❑No Does your business handle a hazardous material in any quantity at any one tune in the year? See the definition of hazardous material on the back of this form. If your answer is"No",go to Question 4. Q2. MYcs" ❑Pio rkxa 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. It"Yes",how long have you handled these materials at your business? N/A If "Yes",check any of the following conditions that applies to your business? 17 A. 'fine hazardous materials handled by this business is contained solely In a consumer product packaged for direct distribution to,and use by,the general public. ❑B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses snly mediae gases. ❑C. Thix business opersres a farm for purposes of cultivating the soil,raising,or harvesting an agricultural or horticultural commodity. Q3. ❑Yes jjNo Does your businccc handle an Acutely Hn7Anlntt.Material? See definition on reverse side of this form. Q4. ❑Yes .f lNo Is your business within 1,000 feet of the outer boundary of a school(grades K-12)? I have read the information on this form and understand my requirements under Chapter 6.95 of the California Heatdl and Safety 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 tiro 1uluirroutc1lts which nmst In;mct prior to issuance of a Ccriinr tc of Occupawy Ur beginning of operations. 1 declare under due penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owncr or Authoriu:d Agent: X Sean Nix,Agent for Walgreens Corporation Date 12/31/2009 Prin[ e Na Title Associate Regulatory Specialist,3E Company Signature (Rev 10/96)