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SAN JOAQUIN COUNTY 0SCE VED SAN JOAQUIN COUNTY <br /> AGRICULTURAL HAZARDOUS 1 OFFICE OF THE <br /> ENVIRONMENTAL HEALTH DEPARTMENT UN - 2011 AGRICULTURAL COMMISSIONER <br /> 600 E MAIN ST <br /> STOCKTON,CA 95202-3029 MATERIALS INVENTORY SqN J0 OUNTY 2103 E.EEKTONAcA 95206100 <br /> PHONE(209)468-3420 <br /> / �3/ � ENCYS�y�a PHONE(209)953-6000 <br /> Part I:General Information <br /> Business,Farm or Ranch Name: Site Locations/Address include zip code): Phone No: <br /> 17716 . 9S•2-2-7 20?-75-7-32-0/ <br /> 3 . L t e YL 1 PK rem c t,ew%.0 { CA - <br /> Mailing A dress(if different from above): Description of Business/Operation(Farm,Nursery,Etc.):, Nearest Crossroad: <br /> o -,,'4 0X 6oL( ejemeA,;` C'.e �1cS7-�-7 fg4" /9/017N5 �- <br /> Emergency Contact Person: Phone No: Pesticide Permit/ID No: Fire District: <br /> 5-Fevc t� 23i t_a�Kf' 209- X59-3ao/ 34-11-39 - oV-0q'7 <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 Locations(s)on the property(e.g.in barn,NW <br /> Type of Containers corner of property) <br /> at an I time <br /> 17-7/5- Wy OV <br /> 90 ?Ivwc{ tc 1$41 aIJFMAMJJAS0ND jho S w�l, ceN4ee <br /> _L{ - 2-76S1�1gc},c �/ p � JFMAMJJASON 1-171 EM g elenLLAAS <br /> P� Yt l0 IbS Q JFM MJJASOND Cra AS�2Z <br /> ,L ANVAI Wt <br /> AJC �7s•2- lqJJA.c � c. ( I (� / U JFMA OND t \ <br /> V� /� <br /> YI1 11'I" ( DN ;t.;I- S� ?11rC4- 2 1�LGA� Ib JFMAM JAS ND t t t <br /> !(� ti 1- a781 ?IpCt tc s7 Ifi(7 JF A M J J 3Ab ND t t \ \ <br /> I elsz ( 1Q0.3 5> ee t 3000 R JF AMJJASO D t <br /> {} 10 S4-6e loon /}1 <br /> JFMAMJJASOND (L <br /> /?cop L i Q -7 S 3000 qrf(5 JF MAMJJASE@D <br /> JFMAMJJASOND ( L L <br /> JFMAMJJASOND t 1 L 1. <br /> certify that the above hazardous material information is true and correct to the best of my knowledge. / <br /> s 4;if--yie-/1/ 6 !�i[ >°2 / S o� 'f-t! Additional Inventory Sheets Attached: <br /> `Signature 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.) IIECENED:rev. 10/15108) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br /> MAY 31 2011 <br /> ASR rnneee - ernPVTnm <br />