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Ur 13 , M661G5b ,i R0�2I--�d9 , FV -6':) <br />COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES RONALD E. BALDWIN <br />Room 610, Courthouse DIRECTOR of <br />222 East Weber Avenue <br />MM <br />Stockton, California 95202 <br />Telephone (209) 468-3962 <br />Hazardous Materials Division (209) 468-3969 `�� ���� <br />"'1VIAC?NAQFNFAL F <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY pFMprQERVr <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: <br />Constellation Brands / �,Ioodbrid.-e Winery <br />Business Owner(s) Name: Constellation Brands / U.S. Telephone: <br />209-369-5861 <br />Business Address: 5950 E. doodbridge 'Rd., Acampo, CA 95258 <br />Mailing Address (if different from above): P.O. Box 12 60 , 'g o odbr i d}ge , CA 95258 <br />Nature of Business: .^finery Fire District: Liberty <br />Q1. <br />Yes ONo Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br />of hazardous material on the back of this form. If your answer is No," go to Question 4. <br />Q2. Ayes ONo Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <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? 30 yrs + <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 onlymedical 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. Ales ONo Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br />Q4. DYes ko 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 Mr. Jim Crandell Date: 9/15/16 <br />jPri(1qame Facilities Director <br />X Title: <br />Signature <br />F:\Devsys\Planning Application Forms Page 1 of 2 <br />Hazardous Materials Disclosure Survey (Revised 8-25-03) <br />