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SAN JOAQUIN COUNTY �G�c t^ E® SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LTURAL HAZARDOUS OFFICE OF THE <br /> 600 E MAIN ST AGRICULTURAL COMMISSIONER <br /> STOCKTON,CA 95202-3029 JAN t� l l 'ERIALS INVENTORY :IA,fy ' ' `' 2101 E.Earhart Ave.,Suite 100 <br /> PHONE ,C 46&3420 STOCKTON,CA 95206 <br /> PHONE(209)953-6000 <br /> Part 1:General Information OFFIM OF EMERGE!11" — <br /> SANJOAQUINCOUNTY p��. COW - STOCKTON <br /> Business,Farm or Ranch Name: Site Lacations/Address(include zip code): /7P/3r jE AfWy Phone No: <br /> 21 ✓LI-6z i F-#+Krv% 9s�2a7 C/enPe/vfs 20q-- <br /> Mailing <br /> oa Mailing Address(if different from above): Description of Business/Operation(Farm,Nursery,Etc.): Nearest Crossroad: <br /> ?o l3t�x (2oLf C�levoelt>Fs C�,. 9sa�� � i u�,-/.vu� rr� . ���� s Ak/Ns 4- 0 <br /> Emergency Contact Person: Phone No: Pesticide Permit/ID No: Fire District: <br /> ao9- -2SY-3;Z&'1 3zz_�o-39-040517 C° I'ewtte_fv4-s G <br /> Part If: Hazardous Material Information Refer to the Agricultural Hazard Material Worksheet for the materials that should be listed below and their reportable quantities) <br /> Material Name DOT# Container Container Size Max.Number Circle the Months On Site Locationsts)on the property(e.g.in barn,NW <br /> Type of Containers corner of property) <br /> at any I time <br /> PSCI Iaa3 S}ted �p ;;Ooo I — JFMAMJJASO �G STX3 <br /> coJF JJASOND l <br /> JFMAMJJASOND <br /> ❑ I certify that the above hazardous material information is true and correct to the best of my knowledge. <br /> .STV -7W 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 inventpi y. p;VmPnt will be <br /> collected based on invoicing by the Environmental Health Dept.) 11 "" RRff��LLLLII (rev. 10/15/08) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br /> Ja,U 15 2010, <br /> AGR_ 0OMM. - STOCKTON <br />