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SAN JOAQUIN Environmental Health Department COUNTY Greatness grows here . HAZARDOUS MATERIALS DISCLOSURE SURVEY A separate survey form is required for each business name and /or address in San Joaquin County . Business Name : SMVA Trust Religious Assembly Telephone : 650 - 793 - 0054 Business Site Address : 6001 Stanley Road , Stockton , CA 95215 Mailing Address ( if different from above ) : Business Owner ( s ) Name : SMVA Trust ( Vinay Mamidi - Authorized Owners Rep . ) Telephone : 650 - 793 - 0054 Business Owner Address : 1312 North Rd , Belmont , CA 94002 Nature of Business : Religious Assembly Fire District : Farmington Q1 . o 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 w 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 01 , please print , sign , and date the bottom of this form and return to the address above . Q2 . ❑ Yes w 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 ? 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 o No Is your business within 1 , 000 feet of the outer boundary of a school ? ( Grades K- 12) I 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 : 2023 - 12 - 20 Print Name : Vinay Mandl Date : 2023 - 12 - 20 Signature : Title : 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 www . sicehd . com