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Environmental Health Department JOAQUIN SAN " COUNTY 1100033 HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and /or address in San Joaquin County . Business Name : New Cingular Wireless PCS d/b/a AT&T Mobility Telephone : 916-764-2632 Business Site Address : 19455 E. Highway 26 , Linden, CA 95236 Mailing Address ( if different from above ) : 2009y St, Sacramento, CA 95818 Business Owner(s) Name : AT&T Inc . Telephone : Business Owner Address : Nature of Business : Telecommunications Fire District: Linden-Peters Q1 . aYes ❑ 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 n 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 m 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? 54 gallon diesel tank proposed. 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 N No Does your business handle an Acutely Hazardous Material ? See definition on page 2 . Q4 . ❑ Yes i2� 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 . gov to submit your hazardous materials information . Owner or Authorized Agent: Print Name : Kevin Gallagher, Complete Wireless Consulting Date : 2/ 10/21 Dlgltallyslgned by Ke%ln Gallagher DN: m=KeAn Gallagher, o{pmplete Wlreless Kevin Gallagher emsl=kgalnu, email=kga Ilagher@cnmpletewlreless<ansultingm t, C=,5 Agent Signature : Datelo2,.82.,0 ,8:8793 -08DO' Title : g 1868 E . Hazelton Avenue Stockton , California 95205 ( T 209 468 -3420 F 209 464- 0138 1 www . sjcehd . com