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SQN � QQQU � ty Environment... Healtwwh Department <br /> ,.- �-�1 11...1 T "Y P^ � 1 0 0 0 <br /> HAZARDOUS MATERIALS �ISCLOSU RE SURVEY <br /> A s¢parate survey Torm is required Tor each business name end/or atltlress in San Joaquin Cbunty. <br /> Bnaineaa Nama: 40FORTY, LLC relephpne: 209-612-0202 <br /> Buaineas sue Address. 9050 HICKORY HOLLOW STREET <br /> Mailing Atldrass(if different from above): <br /> auainaas owner(a) Nama: JATINDER DHILLON Telephone: 209-Fi92-O2D2 <br /> auaineaa owner Address: 3725 E. ARMSTRONG ROAD <br /> Nature of Buaineas: WINERY/BREWERY l=ire district WOODBRIDGE <br /> Ot. v Yea a No does your business handle a hazartlous material in puant'ty at any one time in the yeaR <br /> See the tlef nRion of hazartlous material on pegs 2 of[his form. <br /> v Yea a No Oo¢s your business genere[e.treat,or store a hazardous waste'n env cuantily?(usatl oil,used <br /> anfifreeza,waste solvent,sic.) <br /> M your anawar Ia"No"tp both quaatlona In Ot,please print,algn,antl tlata[ha boHom of thio form Intl return to[ha atltlresa above. <br /> Q2. o Yes o No Ooas your buainesa handle a hazartlous material,or a mixture containing a hazardous material, <br /> a quantity equal to or greeter than 55 gallons.500 pounds,or 200 cubic feet et any one time <br /> in[he y¢ar? <br /> If"Yes", how long have you hantlletl[hese materials a[your business? <br /> It"Yes", check any of[he fallowing conditions that apply fo your buainasa: <br /> v A. The hazardous materiels handled by Shia business ora contained solely In a consumer product <br /> packagetl for direct distribution to and use by the general public. <br /> v B. This business opereles a farm for purposes of cultivating the soil, reising or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. v Vas v No Does your business hantll¢an Acutely Hazardous Material? Sae deflnihon on page 2. <br /> 04. o Y¢s v No Is your business within 1,000 feet of the outer boundary of a school?(crease k-1 z) <br /> I have reatl[he information on this form and understand my requirements untl¢r Chapter 6.95 of the California Health and Safety <br /> Coda(HSC). I understand that if I own a facility or property Shat is used by fanan[s,it is my responsibility[o notify th¢tenants of Iha <br /> requirements which must be m¢t prior to Issuance of a Certificate of Occupancy or beginning of operations. I daGara under[ha <br /> penalty of p¢rjury that[he information provided on this disclosure survey is[rue and accurafa to the bast of my knowledge. <br /> If you answeretl"Yes'[o Question 2, please go online to c colada v to aubmi[your hazardous materials information. <br /> Owner or Authorizetl Agent <br /> I=rint Name: Jatinder Dhillon oat¢: 2/7 x/21 <br /> Signature: B'� �- Titl¢: Ovtrnar <br /> 1868 E. Hazelton Avenue Stockton, Galifornia 95205 T 209 468-3420 i F 209 464-0138 www.sjcehtl.com <br />