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r s k f COUNTY OF SAN' OAQUIN N OFFICE OF EMERGENCY SERVICES :< 2101 E. Earhart Avenue, Suite 3-- Stockton, California 95202 Telephone (209) 953-6200 . Fax (209) 953-6268 HAZARDOUS MATERIALS DISCLOSURE SURVEY 4 Please read the information on the reverse side before completing this survey form. A separate su name and/or address in San Joaquin County is required. p. rvey for each business Business Name: Energy Alchemy TA Vernalis, LLC(Business License application filed concurrently Application rrently with Site Approval Business Owners) Name. . Ene yAlchem , LLC - Telephone: j4115) 845-2007 Business Address: 36314 South Bird Road, #B, Trac , CA 95304 Mailing Address (if different from above): 2456 ClaZ Street, San Francisco, CA 94115 Nature of Business: Develop and own'wind energy facility on customer site. Fire District: Trac Rural Q1. Oyes L7No Does your business handle a hazardous material in any quantity at any one time in the year? Seethe definition of hazardous material on the back of this form. If yo r answer is No Q2. !]Yes D ,,go to Question 4. No Does your business handle a hazardous material, or a mixture containing a hazardous material in a quantity equal to or gfeater than 55 gallons, 500 pounds, or 200cubic feet at.,any one time in the year? if"Yes," how long have you handled.these materials at your business? If"Yes,"check any of the following conditions that applies to your business. DA. The hazardous materials handled by this business is contained solely in a consumer product, i packaged for direct distribution to,.and use by, the general public. • j' ❑B. .This business is a health care facility(doctor, dentist, veterinary, etc.) and uses only medical gases. OC. This business operates a farm for purposes of cultivating the soil, raising, or harvesting an agricultural or horticultural commodity. Q3. OYes ONO Does your business handle an acutely hazardous material? See definition on reverse side of this form. Q4. ©Yes ONo is your business within 1,000 feet of the outer boundary of a school (grades K-12)? I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety Code. 1 understand that if I own a facility or property that is used by tenants, that it is -my responsibility to notify the tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. Owner or Authorized Agent: X Jeffre C. Hoelsken Date: 9 3 p Print Name X Title: General Counsel Signature i.