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SAN JOAQUIN Environmental Health Department 1 4 I_ I COUNTY - Greatness OUNTYGreatness 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 : Assurance Development ( obo/ Vertical Bridge ) Telephone : 323 - 573 - 0045 Business site Address : 1499 Huntington Dr , Suite 305 , South Pasadena , CA 91030 Mailing Address ( if different from above ) : Business Owner ( s ) Name : Bill Lewis Telephone : 626 765 5079 ext . 101 Business Owner Address : 1499 Huntington Dr , Suite 305 , South Pasadena , CA 91030 Nature of Business : Telecommunication Facility Development Fire District : Tracy Rural Q1 . ❑ Yes a 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 ❑ 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 Q1 , please print, sign , and date the bottom of this form and return to the address above. Q2 . ❑ Yes ❑ 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 ❑ 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 : Print Name : Elliott FrolSsart Date : 6 /27 /2023 Signature : CV&7)1: .d� Title : Site Acquisition 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468 - 3420 1 F 209 464 - 0138 I www . sjcehd . com