Laserfiche WebLink
7Ul/25/2017/TUE 06:36 AM FAX No. RECEIVED <br />San Joaquin county <br />Environmental Health Department <br />1868 E Hazelton Avenue <br />Stockton, California 95205 <br />Website: www.sjgov,org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />JUL 2 5 2017 <br />EIb1RlF/MENTAL HEALTH <br />Ponn64l"—.FM E N T <br />raq_fitsI MENT <br />PROGRAM COORDINATORS <br />Pobert McClellon, RENS <br />Jeff Carfve800, REHS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, BENS <br />Rodney Estrada, REHS <br />Adrienne Eilsaosser, kr-H5 <br />HAZARDOUS MATERIALS DISCLOSURE SURVEY <br />A separate survey form is required for each business name and/or address in San Joaquin County. <br />Business Name: AT&T Mobility <br />Business Site Address: 3720 Pacific Avenue <br />Telephone, N/A <br />Mailing Address (if different from above): <br />Business Owner(s) Name: AT&T MobilityTelephone: 916 486-3033 <br />Business Owner Address: 2700 Watt Avenue, SLiite 2200-26, Sacramento, CA. 9582"1 <br />Nature of Business: WirclesS TP-.iecomnignlcatlon Fire District.- <br />01, <br />istrict: <br />Q1. ❑ Yes )0 No <br />Does your business handle a hazardous material irLany puantity at any one time in the <br />year? See the definition of hazardous material on page 2 of this form. <br />❑ Yes M No <br />Does your business generate, treat, or store a hazardous waste in any quantity? (used oil, <br />used antifreeze, waste solvent, etc.) <br />If your answer Is "No" to both questions in Qt, please print, sign, and date the bottom of this form and return to the addre9s above. <br />Q2. n Yes w No <br />Does your business handle a hazardous material, or a mixture containing a hazardous <br />material, in a quantity equal to or greater than 55 gallons, 500 pounds, or 200 cubic feet at <br />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 apply to your business: <br />❑ A. <br />The hazardous materials handled by this business are contained solely in a consumer <br />product packaged for direct distribution to and use by the general public. <br />❑ B. <br />This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br />agricultural or horticultural commodity. <br />Q3. c Yes n No <br />Does your business handle an Acutely Hazardous Material? See definition on page 2 <br />Q4, o Yes :o No <br />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 5.95 of the California Health and <br />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 <br />tenants of the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I <br />declare under the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of <br />my knowledge. <br />Owner or Authorized Agent: <br />Print Name: Todd Peak Date. 7117117 <br />Signature: Title,. <br />1 <br />Rwlnsd i 11Ub1 @ <br />