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San Joaquin County Environmental Health Department 1868 E Hazelton Avenue Stockton, California 95205 Website: www.sjgGv.org/ehd Phone: (209) 468-3420 Fax: (209) 468-3433 DIRECTOR Donna Heran, REHS PROGRAM COORDINATORS Robert McClellon, REHS Jeff Carruesco, REHS, RDI Kasey Foley, REHS finds Turkatte, REHS Rodney Estrada, REH5 Adrienne Ellsaesser, REHS HAZARDOUS MATERIALS DISCLOSURE SURVEYRECEIVED A separate survey forth is required for each business name and/or address in San Joaquin County -9 U 5 2014 Business Name: Shell Supply and Distribution Business site Address: 3515 Navy Dr., Stockton, CA Mailing Address (if different from above): 209-446-AVALROIVMEN I Telephone: ALTHneoer, NT' Business Owner(s) Name: Shell Supply and Distribution Telephone: 209-446-6941 Business Owner Address: 3515 Navy Dr., Stockton, CA Nature of Business: Supply of Refined Oil Products Fire District The Tank Realignment and Premium Pump Proiects do not change the amount of hazardous materials at the site Qt. d Yes ❑ No Does your business handle a hazardous material in am quantity at any one time in the year? See the definition of hazardous material on page 2 of this form. o Yes ❑ No Does your business generate, treat, or store a hazardous waste in any quantity? (used oil, used antifreeze, waste solvent, etc.) If your answer is "No" to both questions in Qt, please print, sign, and date the bottom of this form and return to the address above. Q2. b,Yes ❑ No Does 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? if HZ is generated, it is If 'Yee, how long have you handled these materials at your business? mere than If Yes', check any of the following conditions that apply to your business90 days eA. The hazardous materials handled by this business are contained solely in a consumer product packaged for direct distribution to and use by the general public. ❑ B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an agricultural or horticultural commodity. Q3. u Yes 6 No Does your business handle an Acutely Hazardous Material? See definition on page 2. Q4. o Yes pNo 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 Health and Safety Code (HSC). 1 understand that if I own a facility or property that is used by tenants, it is my responsibility to notify the tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owner or Authorized Agent: Print Name: Jorge L Beltran Jan -3-2014 Signature: /�/"`-� ' Title: Supervising Engineer at Worley Parsons