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/ . I}�vlHmmPl � <br /> RECEIVED <br /> h. <br /> OL 1 2 2 M4 14 COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> NVIRONMENTALHEMTH Room 610,Courthouse DTRECTOROF <br /> PERMIT/SERVICES 222 East Weber Avenue EMEROFNCY OPERATIONS <br /> Y Stockton,California 95202 <br /> Telephone(209)468-3962 <br /> Hazardous Materials Division(209)468-3969 <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 name <br /> and/or address in San Joaquin County is required. <br /> Business Name: Constellation Brands / Woodbridge Winery <br /> Business Owner(s)Name. Constellation Brands U.S. Telephone: 209-369-5861 <br /> Business Address: 5950 E- Woodbridge Rd. , Acampo, CA 95220 <br /> Mailing Address(if different from above). P. O. Box 1260. 'Woodbridge. CA 95258 <br /> Nature of Business: Winery fire District: Liberty <br /> Ql. Xes ONo 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.Wes 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 200eubic feet at any one time in the year? <br /> If"Yes,"how long have you handled these material,at your bossiness? 30 yrs + <br /> If"Yes,"check any of the following conditions that applies to your business. <br /> 9A. The hazardous materials handled by this business is contained solely in a consumer puoduM packaged for direct <br /> distribution to,and use by,the general public. <br /> OB. This business is a health care facility(doctor,dentist,veterinary,etc.)and uses only medical gases. <br /> OC. This business operates a farm for purposes of cultivating the soil,raising,or barvesting an agricultural or <br /> horticultural commodity. <br /> Q3.VYes [[No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. OYes ,*o fs yourbusin ss 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 Safety <br /> Code. I understand that if I own a facility orpmperty that is used by tenants,that it is my responsibility to notify the tenants of the <br /> requirements which must be met prior to issuance of a Certificate of Occupancy at beginning of operations. I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurarc to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> x ;Tt yA CDate: Z127�2-61g <br /> / tName <br /> x Vd • Title: F' l L};�s b i r+.r L�7 rL <br /> Signature <br /> Fwevsyswtenrdg ApskcalIm Fonar Pagel of 2 <br /> Hazardous Materials Materials Dlsdasns Survey(Ravlsed 8-2503) <br />