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T <br />C IVE'DoFFI C O EMERGENCY SERVICES <br />Room 610, Courthouse <br />E13 14 2017 222 East Weber Avenue <br />TALH Stockton, California 95202 <br />ERVIROHM Telephone (209) 468-3962 <br />pERTjRNOEHazardous Materials Division (209) 468-3969 <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />RONALD E. BALDWIN <br />DIRECTOR OF <br />EMERGENCY OPERATIONS <br />Please read the information on the reverse side before completing this survey form. A separate survey for each business name <br />and/or address in San Joaquin County is required. <br />Business Name: <br />Business Owners) Name: <br />Business Address: <br />McManis Family Vineyards, Inc. <br />McManis Family Vineyards, Inc. <br />Telephone: 2 0 9- 5 9 9-118 6 <br />18700 E. River Rd. , Ripon, CA 95366 <br />Mailing Address (if different from above): <br />Nature of Business: Farming / Processin{� Grapes <br />Fire District: Ripon <br />Q1. DYes �No Does your business handle a hazardous material in any quantity at any one time in the year? See the definition <br />of hazardous material on the back of this form. If your answer is No," go to Question 4. <br />Q2. DYes ONo Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity <br />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? 17 + years <br />If "Yes," check any of the following conditions that applies to your business. <br />DA. The hazardous materials handled by this business is contained solely in a consumer product, packaged for direct <br />distribution to, and use by, the general public. <br />DB. This business is a health care facility (doctor, dentist, veterinary, etc.) and uses only medical gases. <br />DC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or <br />horticultural commodity. <br />Q3. DYes �No Does your business handle an <br />acutely hazardous material? See definition on reverse side of this form. <br />Q4. DYes ONo Is your business within 1,000 feet of the outer boundary of a school (grades K42)? <br />I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health an <br />d Safety <br />Code. I understand that if I own a facility or property that is used by tenants, that itis my responsibility to notify the tenants of the <br />requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br />penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br />Owner or Authorized Agent: <br />Mr . Mike R c�buste3:1 i <br />Signature <br />F:\Devsys\Planning Application Forms <br />Hazardous Materials Disclosure Survey (Revised 8-25-03) <br />Winemaker <br />Page 1 of 2 <br />