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COUNTY OF SAN JOAQUIN OFFICE OF EMERGENCY SERVICES Room 610,Courthouse 222 East Weber Avenue — ' Stockton, California 95202 Telephone(209)468-3962 Hazardous Materials Division (209)468-3969 HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the Information on the reverse side before completing this survey form. A separate survey for each business name andlur address In San Joaquin County Is required. Business Name: Pilot Travel Center $142 (proposed) Business Owner(s)Name: Pilot Travel Center, LLC Telephone: (865) 588-7488 x2777 Business Address: S. Tlarlan Road_ French Camp. CA 95231 Mailing Address(it different from above): 5508 Lomas Road, Knoxville, TN 37909 Nature of Business: Travel Centex/Mercantile Flee District: 01. MYes ONo 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 IRYes OND Does your business handle a hazardous material,are mixture containing a hazardous material In a quantity equal to or greater than 55 gallons,500 pounds,or 200cublc feet at any one time In the year! If"Yes,"how long have you handled these materials at your business? 01 1 if"Yes,"check any of the following conditions that applies to your business- ,kA. The hazardous materials handled by this business Is contained solely Ina consumer product, packaged for direct distribution to,and use by,the general public. CB. This business Is a health care facillty(doctor,dentist,veterinary,etc.)and uses only medical gases. OC. This business operates a farm for purposes of cultivating the soil,raising,or harvesting an agricultural or horticultural commodity. 03. OYes)AN- Does your business handle an acutely hazardous material? See definition on reverse side of this term.. Q4. L1Yes)t IVo 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 SafetyCode. I understand that If I own a facilityor property that Is used by tenants,that It Is my responsibllily to notify the tenants of the requirements which must be met prior to Issuance of a Cerliflcele of Occupancy or beginning of operations. I declare under the penalty of perjury Ihat the information provided on this disclosure survey is[rue and accurate to the bast at my knowledge- Owner or Authorized Agent: y�-J xI'At e�IQ 115 Date: xName Tide: 6 Ili r �f� IG(%f /l/�CtrtR dill ure F toEvsvc�wan�anv Applk.,non ramu�r•Apc ,.L. Ro01,d r rice) Page 6 of 9