Laserfiche WebLink
RA((tN COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD 6.BALDWIN <br /> c <br /> s< ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> TELEPHONE(209)468-3962 D <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 (�`'� �p D <br /> ^' NW <br /> CARBON DIOXIDE DISCLOSURE SURVEY <br /> SAN J"oAQUIN Y <br /> OMCE OF EMERGENCY SERWES <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business name <br /> and/or address in San Joaquin County is required. <br /> Business Name M e-iwna t d `s ^*� (4 � �^/ 9��p� <br /> Business Owner(s)Name—Don �y 1(�+i rin'(��/U'� �� -- �/y� / Telephonep`f 0�y��Z <br /> Business Address �O f l a�'�t.-t� cv,",",,A4 3-V-41 Caa��,., n 1 /��p` ce <br /> Mailing Address(if different <br /> \from <br /> �above)`I 'R fig '�t dDwn PI• 5. H I k CC, �"V 6 7 <br /> Nature of Business M cb `cu d.5 ga nbumerS Fire DistrictLJ <br /> S ✓I <br /> Ql: Yes ❑ No Does your business handle Carbon Dioxide(CO2)in any quantity at any one time during the year? <br /> Q2. C Yes &Io Does your business handle Carbon Dioxide(CO2)in a quantity equal to or greater than 1,200 cubic feet <br /> or 137 pounds at any one time during the year? <br /> I have read the information on this forth and understand my requirements under Chapter 6.95 of the California Health and Safety <br /> Code. I understand that if I own a facility or property that is used by tenants,that 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 the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent- <br /> X -! Date q <br /> Print Name <br /> XTitleco <br /> ignature <br /> (9/98) <br />