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RECEIVED <br /> SAN JOAQUIN COUNTY - A g q q SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AGRICULTURAL HAZARDOUS JAN 3 2012 OFFICE OF THE <br /> 600 E MAIN ST AGRICULTURAL COMMISSIONER <br /> STOCKTON,CA 95202-3029 MATERIALS INVENTORY POST OFFICE BOX 1809 <br /> PHONE(209)468-3420 SAN JOAOUI GOUMY STOCKTON,CA 95201-1809 <br /> Part I:General Information <br /> l l-D NGY SERVIM PHONE(209)468-3300 <br /> Business,Farm or Ranch Name: Site Locations/Address(include zip code: Phone No: <br /> �3 Lt epi �� tS E Nwy Su Olerx��+�k 9ra�7 i-7s�-3-bi <br /> Mailing Add (if different from above): Description of Business/Operation(Farm,Nursery,Etc.): Nearest Crossroad: <br /> o '130 (VOY ��,ev>z lit <br /> Emergency Contact Person: . Phone No: Pesticide Permit/ID N Fire District: <br /> S-f-e 6A) L�et�. c a.Dq - 75"i� 3 goow � C le►xep+ <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 Max.Number Circle the Months On Site Locadonsts)on the property(e.g.in barn,NW <br /> 1 Type of Containers corner of property) <br /> ` at any 1 time <br /> Q C� qq3 1000 JFMAMJ ASO D 5at4l, kZ j4W10 <br /> Gm. 1000 ( JF AMIIASOND <br /> P <br /> ArV%0"NC $ 1 1'Iw4t- ;Z I/ &AW 3 JFMA JJASO D S1 e S�A0 <br /> Cnpvem LJ I-P� q '0Q JFMAEJAS0ND <br /> ep Q ls)Lti� orllo 1 FMA ASON SO S 0 <br /> ©'l 2-7o G4t e JFMAMJJASON S 6 jo <br /> Ozt cl 1801 J F M6 MJJAS0N SVVAfKt SI. <br /> JFMAMJJASOND <br /> 31 JFMAMJJASOND <br /> JAM REL-eBVED <br /> JFMAMJJASOND <br /> TOCKTON JFMAMJJASOND JAN 2 <br /> 6 ZUTZ <br /> ❑ I certify that the above hazardous material information is true and correct to the best of my knowledge. AGR. COMM. - STOCKTON <br /> J�s�X/rt. GJu a1 ��G U'e Jit. vJ lc,L 1 etL c 1-0- 01Additional Inventory Sheets Attached: <br /> Signature U Name(please print) Lf Date I 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. 10/25/07) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br />