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U,N San Joaquin County <br /> °ateEnvironmental Health Department DLiindaTuurrkkatte, REHS <br /> Q: a 1868 E Hazelton Avenue <br /> Stockton, California 95205 PROGRAM COORDINATORS <br /> Robert McClellon, REHS <br /> Jeff Carruesco, REHS, RDI <br /> Website: www.sjcehd.com Kasey Foley, REHS <br /> Phone: (209)468-3420 Adrienne Ellsaesser, REHS <br /> Rodney Estrada, REHS <br /> Fax: (209) 464-0138 Willy Ng, REHS <br /> CARBON DIOXIDE DISCLOSURE SURVEY <br /> Please read the information on the reverse side before completing this survey form. A separate <br /> survey for each business name and/or address in San Joaquin County is required. <br /> Business Name CSL Plasma Telephone 303-883-6721 <br /> Business Owner Name(s) <br /> Business Address 29 E. March Ln., Stockton, CA 95207 <br /> Mailing Address (if different from above) 900 Broken Sound Parkway, Boca Raton, FL 33487 <br /> Nature of Business blood plasma collection facility <br /> Q1. ❑ Yes V No Does your business handle Carbon Dioxide (CO2) in any quantity at any one <br /> time during the year? <br /> Q2. ❑ Yes ❑vAo Does your business handle CO2 in any quantity equal to or greater than 1,200 <br /> cubic feet or 137 pounds at any one time during the year? If the answer is <br /> "Yes", please visit cers.calepa.ca.gov and submit your hazardous materials <br /> information. <br /> I have read the information on this form and understand that my business may be regulated under <br /> Chapter 6.95 of the California Health and Safety Code relating to hazardous materials and it is my <br /> responsibility to comply with these provisions. I understand that if I own a facility or property that is <br /> used by tenants, that it is my responsibility to notify the tenants of the requirements which must be <br /> met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the <br /> best of my knowledge. <br /> Owner or Authorized Agent: <br /> Barbara Wunder Date 03/24/2021 <br /> Print Name <br /> 3c�.6c� �' Gf�lin:cr�z <br /> Date 03/24/2021 <br /> Signature <br />