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..� 1. 41 <br /> ORgt1,IN C COUNTY OF SAN JOAQUN <br /> OFFICE OF EMERGENCY SERVICES RONALD R.BALDWIN <br /> a ROOM 610,COURTHOUSE COORDINATOR <br /> A <br /> 222 EAST WEBER AVENUE <br /> • r�.., i STOCKTON,CALIFORNIA 95202 R fit (Z M f2 <br /> tls6*�' TELEPHONE(209)468-3962 D LS ltr/ LS U 15 1p <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> W I 1 I�JD 111 <br /> CARBON DIOXIDE DISCLOSURE SURVEY SutlatQumaiuy*;" <br /> OFFICE OF EYERS.ruw <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 <br /> inSann Joaquin County is required. <br /> Business Namen -aqw, jdS � 3on <br /> Business Owner(s)Name Doin Vc ra Qr -Telephone ` p 09 2 <br /> j <br /> BusinessAddress �bgo Low- ( acrameMn 'v_A. <br /> O 3 tt,- ► 1-� � �Isat o <br /> Mailing Address(if different from above) PSW C�Poral _bW e\ 2I M 1 Ca, 0)Sd 0l <br /> Nature of1"� <br /> Business "bm&j ti'3 Ht. * bw Fire District HJT F—I I <br /> Ql. VYefBs ❑ No Does your business handle Carbon Dioxide(CO2)in any quantity at any one time during the year? <br /> Q2. IA Yes VN0 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 /> XDate <br /> Print Name <br /> -XMX Title L <br /> Signature <br /> (9/98) <br />