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V C <br /> SAN JOAQUIN COUNTY E® SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AGRICULTURAL HAZARDOUS OFFICE OF THE <br /> 600 E MAIN ST AGRICULTURAL COMMISSIONER <br /> STOCKTON,CA 95202-3029 MATERIALS INVENTORY JAN 16 1009 2101 E.Earhart Ave_,Suite 100 <br /> PHONE(209)468-3420 1 STOCKTON,CA 95206 <br /> SAN JOAQUIN COUNTY PHONE(209)953-6000 <br /> Part 1:General Information - IM OFFICE OF EMERGENCY SERVICES <br /> Business,Farm or Ranch Name: Site Locations/Address(include zip code), Phone No: <br /> Mailing Address(if different from above): Description of Business/Operalioa(Farm,Nursery,Etc.): Nearest Crossroad: <br /> Emergency Contact Person: Phone No: Pesticide Permit 1 ID No: Fire District: <br /> VZ'- ZIP 3C(o (-mc- b2c <br /> Part II: Hazardous Material Information Refer to the Ag ricultural Hazard Material Worksheet for the materials that should be listed below and their re ortablequantities) <br /> Material Name DOT# Container Container Size Max.Number Circle the Months On Site Locationsts)on the property(e.g.in barn,NW <br /> Type of Containers corner of property) <br /> q (� at any 1 time 1 <br /> Ines 1 �( 7 (, o('o ( . I J A S O N D sdc> Y C) (�41C <br /> � VSdC � 2C3- JFMAMJJASOND d <br /> JFMAMJJASOND 4 U � <br /> JFMANiJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> i <br /> JFMAMJJASOND D MV 4 <br /> JFMAMJJASOND JAN 0 9 2009 `J <br /> JFMAMJJASOND SAN JOAQUINCOUNTY <br /> AGRIO.COMM.LOBI <br /> JFMAMJJASOND <br /> ❑ I certify that the above hazardous material information is true ancam—d correct to the best of my knowledge.\N,,/y CA� p� <br /> `lQ� I f ? .' 2 ���O Additional Inventory Sheets Attached: <br /> Sign Lure 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. 10/15108) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br />