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San Joaquin County <br /> DIRECTOR <br /> '.: Environmental Health Department Donna Hefan.REHS <br /> k 1868 E Hazelton Avenue PROGRAM COORDINATORS <br /> t Stockton, California 95205 Robert McClellon,REHS <br /> � .. Jeff Carruesco.RENS,RDI <br /> Kasey Foley.REHS <br /> Website: www,sjgov.org/ehd Linda Turkade,REHS <br /> Phone: (209)468-3420 Rodney Estrada,REHS <br /> Fax: (209) 468-3433 Adrienne Ellsaesser.REHS <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: Skyway Towers East Side Park Wireless Facility Telephone: 813960-6217 <br /> Business Site Address: 150 N.Sinclair Avenue,Stockton,CA 95215 <br /> Mailing Address(if different from above): 3637 Madaca Lane,Tampa,FL 33618 <br /> Business Owner(s) Name: Skyway Towers,LLC Telephone: 813966-6217 <br /> Business Owner Address: 3637 Madaca Lane,Tampa,FL 33618 <br /> Nature of Business: Unmanned telecommunications facility Fire District:Eastside <br /> Qt. c Yes o No Does your business handle a hazardous material in any quantity at any one time in the <br /> year? See the definition of hazardous material on page 2 of this form. <br /> C Yes o No Does your business generate, treat,or store a hazardous waste in any quantity?(used oil, <br /> used antifreeze,waste solvent,etc.) <br /> If your answer is"No"to both questions in Qt,please print,sign,and date the bottom of this form and return to the address above. <br /> Q2. ❑Yes o No Does your business handle a hazardous material, or a mixture containing a hazardous <br /> material, in a quantity equal to or greater than 55 gallons, 500 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? <br /> If"Yes",check any of the following conditions that apply to your business: <br /> o 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 /> U B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. ❑Yes o No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. o Yes o 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 California 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 perjury 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: Justin Jones Date: 11/1/18 <br /> Signature: ✓ Title: Director of Operations <br /> - 1 <br />