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or.44IN. COUNTY OF SAN JOAQUIN <br /> r. <br /> OFFICE OF EMERGENCY SERVICES <br /> c. < ROOM 610,COURTHOUSE RONALD E.BALD WIN <br /> a: <br /> 222 EAST WEBER AVENUE ORDINATOR <br /> STOCKTON,CALIFORNIA 95202 <br /> 9<ICORN�' <br /> TELEPHONE(209)468-3962 D ft' (µl R nn <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 LS <br /> •- 501 D <br /> CARBON DIOXIDE DISCLOSURE SURVEY <br /> _Of'IC8 JO RGN M <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 /> Joqu <br /> Business Name 1 h e Gradu k, :esi a'wr6 t4 � S <br /> t <br /> Business Owner(s)Name ! / l/'.2!M Evere H l V Telephone <br /> !a^ U 4 <br /> Business Address 2,20 -T <br /> �p(p <br /> ^A gE20c/ <br /> 1. "j <br /> Mailing Address(if different from above) <br /> Nature of Business �y—� ��� <br /> ! Fire District <br /> Ql. F Yes ❑ No Does your business handle Carbon Dioxide(CO2)in any quantity at any one time during the year? <br /> Q2. N�fYes ❑ No 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 form 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: n <br /> X_ � c1r �C�Ica 1, QhQS Dale —t 9—gg <br /> Print Name <br /> X <br /> Title <br /> Signature <br /> (9/98) <br />