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COUNTY OF SAN JOAQUIN <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Telephone (209) 468-3420 <br />FAX (209) 468-3433 <br />Website : www.sjgov.org/ehd <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 <br />name and/or address in San Joaquin County is required. <br />Business <br />Name: NIG LLC <br />Business Owner(s) <br />Name: Markus Niggli Telephone : 209-437-3859 <br />Business <br />Address : 8751 E Highway 12, Victor, CA 95253 <br />Mailing Address (if different from <br />above): PO Box 236, Victor , CA 95235-0236 <br />Nature of <br />Business : Winery Fire District: Mokelumne <br />01 . DYes ~No Does your business handle a hazardous material in any quantity at any one time in the year? See the <br />definition of hazardous material on the back of this form. If your answer is No," go to Question 4 . <br />02. DYes DNa Does 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 200cubic feet at any one 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 />DA. The hazardous materials handled by this bus iness is contained solely in a consumer product , <br />packaged for direct distribution to , and use by, the general public . <br />DB. This business is a health care facility (doctor, dentist, veterinary, etc .) and uses only medical <br />gases. <br />DC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an <br />agricultural or horticultural commodity. <br />03. DYes DNa Does your business handle an acutely hazardous material? See definition on reverse side of this <br />fonn . <br />04. DYes ~No Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? <br />1 have read the information on this fonn and understand my requirements under Chapter 6.95 of the California Health and <br />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 <br />tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations . <br />I declare under the penalty of perj ury that the information provided on this disclosure survey is true and accurate to the <br />best of my knowledge. <br />F/ApplicationsFonn <br />Page 4 of 6