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COUNTY OF SAN JOAQUIN 2 OFFICE OF EMERGENCY SERVICES ? 2101 E. Earhart Avenue, Suite 3— Stockton, California 95202 a�cp� Telephone(2029) 953-6200 FAX(209) 953-6268 HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the information on the reverse side before completing this survey form. A separate survey for each business lame and/or address in San Joaquin County is required. Business Name: Delicate Family Vineyards 3usiness Owner(s) Name: See Ownership Sheet Telephone: Business Address: 12001 South Highway 99 Manteca CA 95336 Niiailing Address (if different from above): Nature of Business:Vineyards and Winery Fire District: Manteca/Lathrop 01 ®Yes ❑No Does your business handle a hazardous material in any quantity at any one time in the year? See the definition of hazardous material on the back of this form. If your answer is"No" go to Question 4. 02.XYes [No Does your business handle a hazardous material, or a mixture containing a hazardous matenal in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet a-,any one time in the year? If"Yes," haw long have you handled these materials at your business? 1924 If"Yes," check any of the following conditions that applies to your business. ZA. 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. This business operates a farm for purposes of cultivating the soil, raising or harvesting and agricultural or horticultural commodity. 03 Yes ®No Does your business handle an acutely hazardous material? See definition on reverse side of this form. 04,LYes ZNo 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 I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate 10 the best of my knowledge. Owner or Authorized Agent: Matt Beiair ( I I21 I I t Print Name Dat— \ } Director of Technical Operations Signature Title F',Devsys/Planting Application Forms 2011-243 Hazardous Materials Disclosure Survey doc Hazardcus Mate-a!s Disclosure Survey(Revised 02-03-10)