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ZF: oP SAN :JOAQUIN - X Environmental Health Department COU NTY grows rows here . , vFoa . 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 Telephone : ( 323 ) 807 - 6571 Business Site Address : 25230 HWY 12 Rd , Clements , CA 95227 Mailing Address ( if different from above ) : 1499 Huntington Dr # 305 , South Pasadena , CA 91030 Business Owner (s ) Name : Bill Lewis Telephone : ( 626 ) 216 - 2024 Business owner Address : 1499 Huntington Dr # 305 , South Pasadena , CA 91030 Nature of Business : Wireless telecommunication faclllty Fire District : Clements Fire Protection District 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 o 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 : 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 . E B . This business operates a farm for purposes of cultivating the soil , raising or harvesting an agricultural or horticultural commodity . Q3 . o Yes o No Does your business handle an Acutely Hazardous Material ? See definition on page 2 . Q4 . a 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 : Print Name : Melissa Keith obo Vertical Bridge Date : 3 /20/23 Signature : Title : Project Representative 1868 E . Hazelton Avenue I Stockton , California 95205 I T 209 468 - 3420 I F 209 464 - 0138 1 www . sjcehd . com