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PA2 100 179 SAN JOAOUIN Environmental Health Department C 0 1.-)NVI, HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and/or address in San Joaquin County. Business Name: Velociter Wireless Inc Telephone: 209-838-1221 Business site Address: 1525 Second Street, Escalon, CA 95320 Mailing Address(if 4ifferent from above): PO BOX 0, Escalon, CA 95320 Business Owner(s)Name:,Ji mVander Dussen Telephone: ,209-613-7025 __.� - _..............._._. __._..__.._... ._. Business owner Address: 16704 Campbell Ave, Escalon, CA 95320 Nature of Business: wireless broadband ._F=ire District: Escalon _ Q1. n,,Yes y;No Does your business handle a hazardous material in any quantity at anyone time in the year? See the definition of hazardous material on page 2 of this form. n•Yes cc.No Dries 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 data the bottom of this form and return to the address above. 02. n Yes rt No goes your business handle a hazardous material,or a mixture containing a hazardous material. in a quantity equal to or greater than 55 gallons,506 pounds,or 200 cubic feet at any one time in the year? if"Yes'',how long have you handled those materials at your business? If"Yes",check any of the following conditions that apply to your businms: o 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. rr 8. ]'his business operates a farm for purposes of cultivating the soil, raising or harvesting an agricultural or horticultural commniodity. 03. rm Yes n No Does your business handle an Acutely Hazardous(Material? See definition on page 2. Q4. r:m Yes a 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 it I own a facility or property that is used by tenants,it is my responsibility to nobly the tenants of time 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.calerm caxiov to submit your hazardous materials information. Owner or Authorized Agent: Print Name: _Jim Vander Dussen Date: 07/20(2021 -__..�. _ Signature: :.._._.._-_....._... ..�...._.__..... _ Title: Owner J 1868 E. 11razelton Avenue l Sl4mcl(tcm, California 95205 1 T 209468-34201 F 209464-0138 1 www.sjcehd.com