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WaG <br /> SAN JOAQUIN COUNTY 't/ED SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AGRICULTURAL HAZARDOUS OFFICE OF THE <br /> 600 E MAIN ST DEC 7 2011 AGRICULTURAL COMMISSIONER <br /> STOCKTON,CA 95202-3029 MATERIALS INVENTORY 2101 E.Earhan Ave.,Suite 100 <br /> PHONE(209)468-342 ' 5206 <br /> JUA IN COUM PHONE(209)953STOCKTON,CA-6000 <br /> L• <br /> Part General Information OMCE OF EMERGENCY SERVICES <br /> Business,Farm or Ranch Name: Site Locations/Address(include zip code): Phone No: G �/ <br /> sC 1 4 KK (tV V /fJ Do-!/ S-.2 Z 20" <br /> Mailing Address(if different from bove): Description of Business/Ope anon(Farm,Nursery,EJ: Nearest Crossroad:� <br /> 19 )130�'D,elfri,es TU Lal , id, <br /> Emergency Contact Person: Phone No 116ticik Permit/ID No: Fire District: <br /> /of Z- - B-3fa VC/L?'/ <br /> Part II:Hazardous Material Information Refer to the Agricultural Hazard Material Worksheet for the materials that should be listed below and their reportablequantities) <br /> Material Name DOT# Container Container Size Maz Number Circle the Months On Site Locations(s)on the property(e.g.in barn,NW <br /> Type of Containers corner of properly) <br /> G at an I time <br /> r <br /> Y Q 1�l i" ` 3 Tatoik <br /> 2ood IJF MA M J J A SON <br /> kvV b 0 la" 5 6r 1 BQ JFMAMJJASOND K <br /> Q� I JFMAMJJASOND y` <br /> NCal �1 3 ° JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND RECEIVED <br /> JFMAMJJASOND DEC 12 2011 <br /> JFMAMJJASOND <br /> I certify Zthat4aVous material information is true and correct to th best of my knowledge. <br /> L �/ltLri L✓✓3� lJe �° Additional Inventory Shefis Attached: <br /> Sign ure V Name(please qnnn D e Yes❑ No <br /> (Return complet forms) to the San Joaquin County Agricultural Commissioner. Do not submit fees with inventory. Fee paymen will be <br /> collected based n invoicing by the Environmental Health Dept.) (rev. 10/15/08) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br />