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I <br /> r ! <br /> 1 <br /> SAN JOAQUZN COUNTY <br /> Eli VIRONN•IENTAL HEALTH DEPARTMENT <br /> ' 1868 East Ha7eiton Avenue, Stockton, CA 95205-6232 <br /> e•.- Telephone (209) 468-3420 Fax 209 464-0138 <br /> ~nnrUw.sjcefld.corn <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey farm is required for each business name and/or address in San Joaquin County <br /> Business Name: BURGER KING#10368 Telephone: <br /> Business Site Address; 4881 STATE ROUTE 99 STOCKTON, CA 95215 <br /> Mailing Address(if different from above): 2821 CROW CANYON ROAD SAN RAMON, CA 94583 <br /> Business Owner(s)Name: AMIR SAHEBALZAMANY Telephone: 925`989-1155 <br /> Business Owner Address: 2821 CROW CANYON ROAD SAN RAMON, CA 94583 <br /> Nature of Business: DRIVE-THRU RESTAURANT Fire District: <br /> Q1. ❑Yes ■No Does your business handle a hazardous material in any quantity at Pny one time in the <br /> year? See the definition of hazardous material on page 2 of this form. <br /> ❑Yes ■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 Q1,please print,sign,and date the bottom of this form and return to the address above. <br /> 02. ❑Yes ■ 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 poundsr or 200 cubic feet at <br /> any one time U 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 /> ❑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 /> a B. This business operates a fawn for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. n Yes 11 No Does your business handle an Acutely Hazardous Material? See defin€tion on page 2. <br /> Q4. ❑Yes ■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 Califomla Health and Safety <br /> Code(HSC). I understand that If 1 own a facility or property that is used by tenants, it is my responsibility to notify the tenants of <br /> the requirements which must be met prior to Issuance of a Certificate of Occupancy or beginning of operations. I declare under <br /> the penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> If you answered"Yes"to Question 2, please go online to cers.caleoa.ca.aov to submit your hazardous materials Information. <br /> Owner or Authorized Agent; <br /> Print Name, JOHN DODSON Date; 6-21-17 <br /> Signature: Title: ARCHITECT <br /> EHD 19-02 1 HNISP SURVEY <br /> Revised 8125116 <br />