Business Name (Same as Facility Name or DBA):*

Business Site Address:*

Contact Name:*

Contact Telephone:*

Contact Email:*

Type of Agricultural Commodity:*

Rice Orchard Row Crops

Livestock Other

If "Other" is checked, please specify:

Total Acreage:*

The storage of certain materials requires a permit due to State or Federal regulations. Please answer the following questions and return the survey back to the Environmental Health Division so that the Environmental Health staff can assist you in determining whether a permit is required and, if so, the type of permit. Should additional information be required, you will be contacted by County staff. Should you have any questions regarding this form, please contact Jesse Kang, Division Manager, directly at 530-458-0396 and he will happy to assist you.

1. Do you have more than 55 gallons of petroleum (gasoline, diesel, kerosene, etc...) based fuel products stored in non-mobile (stationary or permanently placed) containers?*

Yes

No

If the answer to question #1 was "yes", please answer the following questions. If "no", go to question #2.

1a. Do you have a combined storage of 6,000 gallons or more?

Yes

No

1b. Do you have a single tank of 20,000 gallons or more or is your combined storage 100,000 gallons or more?

Yes

No

1c. Do you have a combined storage of between 6,000 gallons and 20,000 gallons with no individual tank greater than 10,000 gallons?

Yes

No

1d. Has there been a spill of a petroleum based material that exceeded 1,000 gallons or have there been 2 spills that each exceeded 42 gallons within any 12 month period?

Yes

No

2. Do you have more than 55 gallons of lubricants (motor oil, hydraulic fluid, ATF, solvents, antifreeze, etc...)?*

Yes

No

3. Do you have a combined storage of more than 200 cubic feet of oxygen or acetylene?*

Yes

No

4. Do you have a combined storage of more than 200 cubic feet of propane?*

Yes

No

4a. If you answered "yes" to question #4, is it solely for heating a work space or to prepare meals and you have less than 500 gallons?

Yes

No

5. Do you have a combined storage of more than 1,000 cubic feet of carbon dioxide, argon, trigas/gold gas, nitrogen, or helium?*

Yes

No

6. Do you have more than 500 pounds or 55 gallons of fertilizers, pesticides or herbicides?*

Yes

No

6a. If you answered "yes" to question #6, is it stored in a mobile container that is moved regularly and used within 30 days?

Yes

No

7. Do you have any used motor oil, used antifreeze, used diesel or used gasoline?*

Yes

No

Survey Completed By:*

Date:*