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San Joaquin County <br /> ot1.t' P DIRECTOR <br /> Environmental Health Department Donna Horan,REHS <br /> 1868 E Hazelton Avenue <br /> Stockton, California 95205 PROGRAM <br /> on REHSOR6 <br /> •,Vie• Jeff Canuesco,REHS,RDI <br /> - KersFoley,REHS <br /> Website: www.Sjgov.org/ehd undo u katte,REHS <br /> Phone: (209)468.3420 Rodney Estrada,REHS <br /> Fax: (209)468.3433 Addanne Effsaesser,REBS <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County. <br /> Business Name: Ameresco San Joaquin LLC Telephone: (209) 825-3479 <br /> Business Site Address: 6484 N. Waverly Rd., Linden, CA 9523 <br /> Melling Address(If different from above): 111 Speen St., Ste 410, Framingham, MA '0170 <br /> Business Owner(s)Name: Ameresco San Joaquin LLC Telephone: (508)661-2200 <br /> .-_ <br /> Business Owner Address: 111 Speen St., Ste 410, Framingham, MA 01701 <br /> Nature of Business: Landfill gas to energy electrical generating st08rbistrct: Linden Peters <br /> of. XYas o No Does your business handie a hazardous material Ih env quantify at any one time in the <br /> Year? See the definition of hazardous material on page 2 of this form. <br /> You o No Doss your business generate,treat,or store a hazardous waste In env on1W(used oil, <br /> used antifreeze,waste solvent,olo.) <br /> If youranswer Is°No"to both questions In Q1,please print,sign,and date fire bottom of this forth and return to the address above. <br /> Q2. X Yes a No Does your business handle a hazardous material, or a mixture contalning a hazardous <br /> material,In a quantity equal to or greater than 55 gallons,SOD 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? New business <br /> If'Yes*,check any.of the following conditions that apply to your business: <br /> ❑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 /> ❑B. This business operates a farm for purposes of cultivating The soil,raising or harvesting an <br /> agricultural or horticultural commodlty. <br /> Q3, o Yes X No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. a Yes X No Is your business within 1,000 feet of the outer boundary of a school?(Grades K-12) <br /> I have read the information on this form and understand my requirements under Chapter 6.95 of the Calffomla 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 periury 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: /Walt . Hitch Data: August 14, 2014 <br /> Signature: Title: - Sr. Project Manager <br />