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COUNTY OF SAN JOAQUIN <br /> Environmental Health Department <br /> 1868 E Hazelton Avenue <br /> Stockton , California 95205 <br /> Telephone (209) 468-3420 <br /> FAX (209) 468-3433 <br /> Website: www. sjgov. org/ehd <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 County is required . <br /> Business <br /> Name: GoldRiver Orchards , Inc . <br /> Business Owner(s) <br /> Name : Don Barton Telephone : 209 . 838 .2000 <br /> Business <br /> Address : 18400 Enterprise Rd . , Escalon , CA 95320 <br /> Mailing Address (if different from <br /> above) : <br /> Nature of <br /> Business : Walnut Processor Fire District: EScalon <br /> Q1 ; Wes ❑ No Does your business handle a hazardous material in any quantity at any 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 . MYes ❑ No 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? 17 years <br /> If "Yes , " check any of the following conditions that applies to your business. <br /> OA. 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 only medical <br /> gases . <br /> ❑ C . This business operates a farm for purposes of cultivating the soil , raising , or harvesting an <br /> agricultural or horticultural commodity . <br /> Q3. MYes ❑ No Does your business handle an acutely hazardous material ? See definition on reverse side of this <br /> form . <br /> Q4o ❑Yes @No is your business within 1 , 000 feet of the outer boundary of a school (grades K- 12) ? <br /> I have read the information on this form and understand my requirements under Chapter 6 . 95 of the California Health and <br /> 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 <br /> tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations . <br /> I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge . <br /> Owner of Authorized Agent: <br /> X ZJeW- Date: 2 2 <br /> N e <br /> Xv Title : �f73 <br /> ignature <br /> Business License Application.pd( 5 2/ 11 /2021 2:59:03PM <br />