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a (CSV <br /> San Joaquin County <br /> PCU IN E �. DIRECTOR C 2 9 Environmental Health Department Donna Heran,REHS <br /> 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> 11 G LA 1 I Robert McClellon,RENS <br /> 'IRTN►LN'r Stockton, California 95205 Jeff Carruesco,RENS,RDI <br /> Kasey Foley,REHS <br /> _ Website: vvvvw.sjgov.org/ehd Linda Turkatte,REHS <br /> Phone: (209)468-3420 Rodney Estrada,REHS <br /> Adrienne Ellsaesser,REHS <br /> Fax: (209)468-3433 <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County. <br /> p <br /> Business Name: <br /> Cepheid Telephone: 408-541-4191 <br /> Business Site Address: 850 Thurman St, Lodi CA 95240 <br /> Mailing Address(if different from above): 904 Caribbean Drive,Sunnyvale CA 94089 <br /> Business Owner(s) Name: Cepheid Telephone: 408-541-4191 <br /> Business Owner Address: 904 Caribbean Drive Sunnyvale CA 94089 <br /> Nature of Business: Molecular Diagnostics Fire District: Lodi <br /> Q1. o Yes [x No Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on page 2 of this form. <br /> o Yes R No 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 Q1,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2. o Yes o No 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 /> o A. 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 /> o B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity <br /> Q3. o Yes e No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. o Yes o No Is your business within 1,000 feet of the outer boundary of a school?(Grades K-12) <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 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: Matthew Gaylor Date: 12/4/2020 <br /> Signature: Wa hew Title: Construction Program Manager <br /> 1 <br /> Revixed 11/67111 <br />