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PA2000072 SAN JOAQUIN 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 : Blyden Limited Partnership , A California Limited Partnership Telephone : Business Site Address : 4343 N . Wilson Way , Stockton CA 95205 Mailing Address ( if different from above) : 3239 W . Ashlan Ave . Fresno , CA 93722 Business Owner(s) Name : erre ) A . Ridenour Telephone : ( 559 ) 269 ® 5155 Business Owner Address : 3239 W . Ashlan Ave . Fresno , CA 93722 Nature of Business . Commercial Fire District : Waterloo - Morada Q1 . ❑ Yes 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 anv quantity? ( used oil , used antifreeze , waste solvent, etc . ) If your answer is " No" to both questions in 01 , 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 I n 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) 1 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 . Qov to submit your hazardous materials information . Owner or Authorized Agent : Print Name : ® Date : °- Signature : Title : 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468 - 3420 1 P 209 464 - 0138 1 www . sjcehd . com