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SAN J O A Q U I N Environmental Health Department COUNTY HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and/or address in San Joaquin County . Business Name : Verizon Wireless Telephone : 949 -259 - 3344 Business Site Address : 2785 Mitchell Drive , Walnut Creek , CA 94598 Mailing Address ( if different from above ) : Business Owner( s ) Name : Verizon Wireless Telephone : 949 -259 - 3344 Business Owner Address : 2785 Mitchell Drive , Walnut Creek , CA 94598 Nature of Business : Wireless Telecommunication Facility Fire District: Q1 . e Yes a No Does your business handle a hazardous material in any quantity at any one time in the year? See the definition of hazardous material on page 2 of this form . ❑ Yes ❑ No 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 ❑ No 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? 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 ❑ No Does your business handle an Acutely Hazardous Material ? See definition on page 2 . Q4 . ❑ Yes ❑ No 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 . If you answered "Yes" to Question 2 , please go online to cers .calepa . ca .goy to submit your hazardous materials information . Owner or Authorized Agent : 1 Print Name : Date : ( Z0 Signature : Title : 9L`-� 1868 E . Hazelton Avenue I Stockton , California 95205 T 209 468-3420 F 209 464 -0138 1 www . sjcehd . com