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RECEIVED JAN 2 8 2016 LTH San Joaquin County Environmental Health Department 1868 E Hazelton Avenue Stockton, California 95205 Website: www.sjgov.org/ehd Phone: (209) 468-3420 Fax: (209) 468-3433 CA-STK060M14.1_NK MVW-- (� DIRECTOR Donna Heran, REHS PROGRAM COORDINATORS Robert McClellon, REHS Jeff Carruesco, REHS, RDI Kasey Foley, REFIS Linda Turkatte, REMS Rodney Estrada, REHS Adrienne Ellssesser, REHS HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and/or address In San Joaquin County. Business Name: Clearwireless LLC / Sprint Telephone: 312-971-7699 Business Site Address: 11230 E. Venture Way, Manteca, CA 95336 Mailing Address (If different from above): Robert Blackie, 540 W. Madison St., 16th Fl., Chicago, IL 60661 Business Owner(s) Name: American Tower Telephone: 781-926-4613 Business Owner Address: -19 100 Von Karmen, Irvine, CA 92612 Nature of Business: Telecommunications Fire District: Q1. o Yes 1SNo Does your business handle a hazardous material in any auentity at any one time In the year? See the definition of hazardous material on page 2 of this form, ❑ Yes Ao Does your business generate, treat, or store a hazardous waste In any quantity? (used oil, used antifreeze, waste solvent, etc.) If your answer Is "No" to both questions In Q1, please print, sign, and date the bottom of this form and return to the address above. Q2. ❑ Yes Ao Does your business handle a hazardous material, or a mixture containing a hazardous material, in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at any one time in the year? I have read the Information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety Code (HSC), I understand that if I own a facility or property that is used by tenants, 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: Print Name: 0,biia Itr * %\a cy", C Date: \,k / k 1 /! S Signature: Title: 2-oe%;r1 h cta..a (tom 1 Revised 11107114 If "Yes", how long have you handled these materials at your business? If "Yes", check any of the following conditions that apply to your business: ❑ A. The hazardous materials handled by this business are contained solely in a consumer product packaged for direct distribution to and use by the general public, ❑ B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an agricultural or horticultural commodity. Q3. ❑ Yes VNo Does your business handle an Acutely Hazardous Material? See definition on page 2. Q4, o Yes Ao 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 (HSC), I understand that if I own a facility or property that is used by tenants, 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: Print Name: 0,biia Itr * %\a cy", C Date: \,k / k 1 /! S Signature: Title: 2-oe%;r1 h cta..a (tom 1 Revised 11107114