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COUNTY OF SAN JOAQUIN <br /> a �t'•.o <br /> _;• i Environmental Health Department <br /> w' 1868 E Hazelton Avenue <br /> Stockton, California 95205 <br /> eq( Telephone (209) 468-3420 <br /> FOR <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 Name: carwoINC.tawJeremy Wine company) <br /> Business Owner(s)Name: Jeremy&C'o'al rreitevik Telephone: 260-367-3778 <br /> Business Address: 12080 Acampo Rd,Acampo,CA 95220 <br /> Mailing Address(if different from above): 6 W. Pine se, Lodi, ca 95240 <br /> Nature of Business: Winery Fire District: Liberty <br /> Q1. ❑Yes ®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. ❑Yes ®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? <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 onlymedical 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. ❑Yes ®No Does your business handle an acutely hazardous material? See definition on reverse side of this form. <br /> Q4. []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 metrior to issuance of a Certificate of Occupancy or beginning of operations. I <br /> P Pa <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 /> Ownef or Authorized Agent: <br /> X Jeremy TretteWc Date: 17120/18 <br /> ri <br /> X Title: President <br /> /16n at Ore <br /> FADEVS/C\Planning Appication FormslSite Approval,(Revised 02-03-10) Page 6 of 9 <br />