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SAN JOAQUIN COUNTY SAN JOAQUIN COUNTY <br /> j ENVIRONMENTAL HEALTH DEPARTMENT AGRICULTURAL HAZARDOUS OFFICE OF THE <br /> s 600 E MAIN ST AGRICULTURAL COMMISSIONER <br /> STOCKTON,CA 95202-3029 MATERIALS INVENTORY 2101 E.Earhart Ave.,Suite 100 <br /> PHONE(209)468-3420 STOCKTON,CA 95206 <br /> a PHONE(209)953-6000 <br /> Part I:General Information <br /> Business,Farm or Ranch Name: Site Locations/Address(include zip code): Phone No: <br /> P4rc-x 1 ' ? "C VN 9 N -t{jC 2.0 <br /> Mailing Address(if differerh from above): Description of Business/Operation(Farm,Nursery,Etc.): Nearest Crossroad: <br /> Emergency Contact Person: Phone No: Pesticide Permit/ID No: Fire District: i <br /> yly\ .0-o \2 tQ=o �0( 3QG f c -Z-!Q 3 ct o 4 %7--Z-o--3�Z Wtzpl 9 4fd, <br /> Part IL• Hazardous Material Information Refer to the Ag ricultural Hazard Material Worksheet for the materials that should be listed below and their reportablequantities) <br /> Material Name DOT N Container Container Size Max.Number Circle the Months On Site Locations(s)on the property(e.g.in barn,NW <br /> Type of Containers corner of property) <br /> at any I time) 1 <br /> �4 �C[irl„� 1�2ca Tw <10 q.3 k FMAMJJASOND t)Gk,r� GP- (�K� <br /> c �SeL 1 [ vt3 'r t:k1CJ JFMAMJJASOND �pcJL G� WV <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND RECEIVED <br /> JFMAMJJASOND JAN 08 20113 <br /> OT-Certify that the above hazardous material information is true and correct to the best of my knowledge. <br /> - r AGR.COMM.-STOCKTON <br /> Additional Inventory Sheets Attached: <br /> Signature Name(please print) Date Yes ❑ No❑ <br /> (Return completed form(s) to the San Joaquin County Agricultural Commissioner. Do not submit fees with inventory. Fee payment will be <br /> collected based on invoicing by the Environmental Health Dept.) (rev. 10115/08) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br />