BLD-2021-0177 PCBPCBs Screening Assessment Form
For Municipality Use Only
Date Received
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complying with all relevant laws and regulations. See Notices to Applicants section in the Applicant Instructions
and at the end of this form.
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Part 1. Owner/Consultant and project information
Owner Information
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JANAKA & SHERRY RANATUNGA
10408 STERLING BLVD
CUPERTINO CA 95014
RICHARD HERNANDEZ
650-391-7425 RICHARD.HERNANDEZPM@GMAIL.COM
GILBERT FERNANDEZ JR
1821 S BASCOM #258
CAMPBELL CA 95008
GILBERT FERNANDEZ JR
408-500-8511 gilbert_fernandezjr@me.com
10408 STERLING BLVD
CUPERTINO 94586
375-24-005
1954
APPROX: 02/01/2021
Wood Frame
Part 2. Is building subject to the PCBs screening requirement based on type, use, and age of
the building?
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Part 3. Report concentrations of PCBs in priority building materials
2SWLRQ Applicants conducted representative sampling and analysis of the priority building materials per the Protocol
for Evaluating Priority PCBs-Containing Materials before Building Demolition (2018) (Attachment C).
2SWLRQ Applicants possess existing sample results that are that are consistent with the Protocol for Evaluating Priority
PCBs-Containing Materials before Building Demolition (2018) (Attachment C).
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Demolition.
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Part 4. Certification
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01/20/2021
RICHARD HERNANDEZ