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COUNTY OF SAN JOAQUIN <br /> ,oQ.go <br /> OFFICE OF EMERGENCY SERVICES RONALD R.BALDWIN <br /> m: , s ROOM 610,COURTHOUSE COORDINATOR <br /> -, 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> c�coeN TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> CARBON DIOXIDE DISCLOSURE SURVEY <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 J A,- k (^i -i WIE;� 13 c", 40 <br /> Business Owner(s)Name o P nA 4 6LE/L I tir L Telephone 4 ( Y ) S--7 J- Z-f B q <br /> Business Address -2-5 � Z 5 Ta c.jc „( C.°t- q5 Ze'7 <br /> � --CrN. �nf�i p�n/nn(s.✓r?� ENtiI.✓Cr Lr2�.✓ t <br /> Mailing Address(if different from above) `�33 e- f3/}LG-A ft vt.! 5.9N <br /> Nature of Business Fire District <br /> QL K Yes C' No Does your business handle Carbon Dioxide(CO2)in any quantity at any one time during the year? <br /> Q2. )k Yes ❑ No 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 J� K_4- Date <br /> Print Name <br /> X -�xr =^T---=_,? Title IM I fes' £'u V, £^iti -w- <br /> Signature Signature V <br /> (9/98) <br />