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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 2101 E. EarhaErt Avenue, Suite 3-- <br /> i Stockton, California 95202 <br /> : Telephone (209)953-6200 <br /> - - Fax(209)953-0268 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> Please read the Information on the reverse side before completing this survey form. A separate survey for each business <br /> name and/or address in San Joaquin Gounty is required. <br /> My Green Vineyards,LLC <br /> Business Name-, <br /> Michael& Debra Green Telephone: (209)368-3091 <br /> Business Owner(s)Name: <br /> Business Address: 6535 E. Peltier Road,Acmapo,CA.95220 <br /> Mailing Address(if different from above): <br /> Nature of Business. Vineyard 1 Winery <br /> Fire District: Liberty Fire Dept. <br /> Q1. tS4Yes DNo Does your business handle a hazardous material in any quantity atany one time in the year? See the <br /> ` , definition of hazardous material on the back of this form. If your answer is No,"go to Question 4. <br /> Q2. VYes DNo Does your business handle a hazardous material,or a mixture containing a hazardous material in a <br /> quantity equal to or greater than 55 gallons; 500 pounds,or 200cubic feet at any one time in the year? <br /> If"Yes,"how long have you handled these materials at your business? <br /> 10 yrs <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> ©A. The hazardous materials handled by this business is contained solely in a consumer product, <br /> packaged for direct distribution to, and use by,the general public_ <br /> ©B. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses on.Iy medical gases- <br /> VC. This business operates a farm for purposes of cultivating the sail, raising, or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3, ®Yes ONO Does your business handle an acutely hazardous material? See definition.on reverse side of this form. <br /> Q4. DYes IBNo Is your business within 1,000 feet of-the outer boundary of a school(grades K-1 2)? <br /> I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and <br /> SafetyCode- I understand that if I own a facility or property that is used by tenants,that it is.my responsibility to notify.the <br /> tenants of the requirements which must be rnet prior to issuance of a�Certificate of Occupancy or beginning of operations. I <br /> declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best <br /> of my knowledge. <br /> Owner or Authorized Agent: <br /> Debra S. Green Date. <br /> L—���--•r~--• Title:, <br /> Signature. <br /> F:oEvsvclpienning appoatinn rorms45ite Approval.(Revised-02-03.10) Page 6 of 9 <br />