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FIF.V'L.IV %v <br /> . rQv x 3 2016 RECEIVED <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES NOV 18 2016 <br /> San Joaquin County COMMUNITY DEVELOPMENT DEPr <br /> Environmental Health Department DK- U,- <br /> 1868E Hazelton Avenue <br /> PROGRAM COORDINATORS <br /> Stockton, California 95205 RobertMcClellan,REHS <br /> F' Jeff Carmesco.REHS,RDI <br /> `P Kasey Foley,REHS <br /> 'LCjFnd'' Website: www.sigov.orgi/ehd Linda Turkaae,REHS <br /> Phone: (209)468-3420 Rodney Estrada,REHS <br /> Fax: (209)468,U33 Adrienne Ellsaesser,REHS <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey forth is required for each business name and/or address in San Joaquin County. <br /> Business Name Constellation Brands Telephone: 209-369-5861 <br /> Business Site Address770 N. Guild Ave. , Lodi , CA <br /> Marling Address(if different from above): P. O. Box 1260 doodbridee , CA 95258 <br /> Business Owner(s)Name Constellation Brands Telephone: 209-369-5861 <br /> Business Owner Address. P• O. Box 1260 doodbrid;-re , CA 95258 <br /> Nature of Business: ,larehouse Distribution Fire District: Lodi <br /> Center <br /> Q1 )(Yes c No Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on page 2 of this form. <br /> )(Yes a No Does your business generate,treat,or store a hazardous waste in any quantity?(used os, <br /> used antifreeze.waste solvent,etc.) <br /> If your answer Is"No"to both questions In 01,please print,sign,and data the bottom of this form and return to the address above. <br /> Q2 9Yes a No Does your business handle a hazardous material, or a mixture containing a hazardous <br /> material,in a quantity equal to or greater than 55 gallons,500 pounds,or 200 cubic feet at <br /> any one time in the year? <br /> If'Yes',how long have you handled these materials at your business? �Y S <br /> If'Yes',check any of the following conditions that apply to your business: <br /> oA. The hazardous matenals handled by this business are contained solely in a consumer <br /> product packaged for direct distribution to and use by the general public. <br /> o B. This business operates a farm for purposes of cultivating the soil,raising or harvesting an <br /> agricultural or horticultural commodity, <br /> 03. o Yes QY440 Does your business handle an Acutely Hazardous Matedal? See definition on page 2. <br /> Q4. o Yes A. 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 <br /> Safety Code(HSC). I understand that if 1 own a facility or property that is used by tenants,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. I <br /> declare under the penally of per)ury that the information provided an this disclosure survey is true and accurate to the best of <br /> my knowledge <br /> Owner or Authorized Agent <br /> Print Name, 021je LW, Date. <br /> Signature <br /> `J✓yi� Title <br /> 1 <br /> a.wa narnr <br /> I �a� l <br />