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COUNTY OF SAN JOAQUIN Environmental Health Department i 1868 E Hazelton Avenue Stockton, California 95205 Telephone (209) 468-3420 FAX (209) 468-3433 Website: www.sjgov.org/ehd HAZARDOUS MATERIALS DISCLOSURE SURVEY Please read the information on the reverse side before completing this survey form. A separate survey for each business name and/or address in San Joaquin County is required. Business Name: Ramon Rios Winery Business Owners) Name: Ramon Rios Telephone: 209-275-3273 Business Address: 8482 W. Llnne Road,Tracy,CA 95304 Mailing Address (if different from above): Nature of Business: To store RV's (Motor Homes) Fire District: Tracy Rural 01. ❑Yes IRNc Does your business handle a hazardous material in any quantity at anyone time in the year? Seethe definition of hazardous material an the back of this form. If your answer is No," go to Question 4. 02. []Yes QNo Does pour business handle a hazardous material, ora mixture containing a hazardous material in a quantity equal to orgreaterthan 55 gallons, 500 pounds,or 200cubic feet at anyone time in the year? If"Yes," how long have you handled these materials at your business? If"Yes,' check any of the following conditions that applies to your business. ❑A_ 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 an agricultural or horticultural commodity. Q3_ ❑Yes ®No Does your business handle an acutely hazardous material? See definition on reverse side of this form. Q4. ❑Yes ❑No 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 Chapter6.95 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 responsibi lityto 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 best of my knowledge. Owner or Authorized Agent: X / / Lab S Date4 "/tf^ oZ Olf' Print Name X Title: Signature MEVSVCU3Wmeg AppfiaLmn Fmm SiB Appmual.(Revised m2-0&10) Page of