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*` COUNTY OF SAN JOAQUIN — .r. .Z•. OFFICE OF EMERGENCY SERVICES 2101 E. Earhart Avenue, Suite 3— ',a '.; Stockton, California 95202 Telephone(2029) 953-6200 FAX (209) 953-6268 HAZARDOUS MATERIALS DISCLOSURE SURVEY -'lease read the information on the reverse side before completing this survey form. A separate survey for each business ,ame and/or address in San Joaquin County is required. 3usiness Name: Delicato Family Vineyards Business Owner(s) Name: See Ownership sheet Telephone: _ Business Address: 12001 South Hiahway 99 Manteca CA 95336 Nlailiog Address(if different from above): Nature of Business:Vineyards and Winery Fire District: MantecatLathrop 01 ®Yes ❑No Does your business handle a hazardous material In any quantity at any one time in the year? See :he definition of hazardous material on the back of this form. If your answer is "No" go to Question 4. 02 ®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"Yes," how long have you handled these materials at your business? 1924 If"Yes,"check any of the following conditions that applies to your business. FJA. The 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 only medical gases ❑C. T^:is business operates a farm for purposes of cultivating the soil, raising or harvesting and agricultural or horticultural commodity. 03 ❑Yes E]No Does your business handle an acutely hazardous material? See definition on reverse side of this form. 04.E]Yes ENo Is your business within 1,000 feet of the outer boundary of a school (grades K-12)? have read the information on this form and understand my requirements under Chapter 6.95 of the California Health 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 the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the hes:of my knowledge. Owner or Authorized Agent: Matt Belair Pnnt Name Date t ) Director of Technical Operations Signature Title 7 A-Pi.cation Forms 2011.243 Hazardous Materlals Disclosure Survey'dcc __ _ 7sclosure Survey(Revised 02-03-10)