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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> _ �•,1 RONALD E.BALDWIN <br /> a < ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> • �'•. STOCKTON,CALIFORNIA 95202 0 V LS <br /> .,cfk• k.N` U <br /> TELEPHONE(209)468-3962 T,FOU - 2W]HAZARDOUS MATERIALS DIVISION(209)468-3969 CARBON DIOXIDE DISCLOSURE SURVEY 504 0AI��.� f <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business name <br /> and/or address in San Joaquin County is required. <br /> Business Name BURGER KING #7628 <br /> Business Owner(s)Name Christian J. Knox ( 209) 367-7693 <br /> gg gg y g 9 B 5 3 Telephone <br /> Business Address X7IIIX&XXXX1�1iKX1{DIXXX&XX&NXX4� X}iX � <br /> Mailing Address(if different from above) 6g3 E Victor Rd #F Tod; CA 9594 <br /> Nature of Business Facet FnnH Fire DistrictMokelumne <br /> Ql. ❑ Yes *o Does your business handle Carbon Dioxide(CO2)in any quantity at any one time during the year? <br /> Q2. 11 Yes �Io Does your business handle Carbon Dioxide(CO2)in a quantity equal to or greater than 1,200 cubic feet <br /> or 137 pounds at any one time during the year? <br /> I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br /> Code. I understand that if I own a facility or property that is used by tenants, that it is my responsibility to notify the tenants of <br /> the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or Authorized Agent: <br /> X Christian J. Knox Date O I <br /> Print Name <br /> X Title President <br /> Signature <br /> (9/98) <br />