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SAN JOAQUIN COUNTY 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 JAIL — 3 2 JJ POST OFFICE BOX 1809 <br /> PHONE(209)468-3420 STOCKTON,CA 95201-1809 <br /> PHONE(209)468-3300 <br /> Part I: General Information <br /> X72. PERCE <br /> SAN CD21MY <br /> Business Farm or Ranch Name: Site Locations/Address(include zip code): Phone No: <br /> /C! � GS G. ,G� ,�. U/its � cam:�l✓�'� � �9 L%6 9-r_3�4� <br /> Mailing Address(if different from above): Description of Rusi ness/Ope ration(Farm,Nursery,Etc.): Nearest Crossroad: <br /> Emergency Contact Person: Phone No: Pes icide Permit/ID No: Fire District: <br /> Part IL Hazardous Material Information Refer to the AR ricultural Hazard Material Worksheet for the materials that should be listed below and their reportablequantities) <br /> Material Name DOT ft 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 1 time <br /> _" i5b JFMAMJJASOND � <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> 01 �— a000..F JFMAMJJASONDTt <br /> A JFMAMJJASOND <br /> ertify that the above hazar usmaterial information is true and correct to the best of my knowledge. <br /> Fr-a��P-57.010 Additional Inventory Sheets Attached: <br /> S' nature Name(please print) Date es M' 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. 10125107) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br />