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SAN JOAQUIN COUNTY SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AGRICULTURAL HAZARDOUS q OFFICE OF THE <br /> 600 E MAIN ST DEC — 2011 AGRICULTURAL COMMISSIONER <br /> STOCKTON,CA 95202-3029 MATERIALS INVENTORY <br /> PHONE 209 468-3420 2101 E. KTO Ave.,Suite 100 <br /> ( ) WIN 10=1 N C STONE(209 C5 95206 <br /> Part 1:General Information <br /> �� OFFICE OF EMERGENCICES PHONE(209)953-6000 <br /> Business,Farm or Ranch Name: Site Locations/Address(include zip code): tNearest <br /> No: <br /> P8 Mailing Address(if different Goma ove): Descripnon of Business/Operation( rm, ursery,Etc.): Crossroad: <br /> Po, <s�Emergency Contact Person: , Phone No: Pesticide Permit/ID No: istrict: <br /> Part 11:Hazardous Material Information Refer to the Agricultural Hazard Material Worksheet for the materials that should be listed below and their reportable uantities <br /> Material Name DOT# 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 <br /> eS� JFMAMJJASOND <br /> ` JFMAMJJASOND <br /> O Y — Y rI `o2 70 ,S'- JFMAMJJASOND <br /> JFMAMJJASOND <br /> r X20 IleAl ,Sbc J F M A M J J A S 0 N <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND RECEIVED <br /> JFMAMJJASOND NOV 2 <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> ET�Icer i that the above hazardous material information is true and correct to the best of my knowledge. <br /> ,Cb�V .� �c�' 1 <br /> a f� eslAdditional Inventory Sheets Attached: <br /> Sign re uName(please print) D e Yes F] NQ6+ <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. 10/15/08) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br />