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SAN JOAQUIN COUNTY SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMENT AGRICULTURAL HAZARDOUS AGRICULTURAL OF THE <br /> COMMISSIONER <br /> 1868 E.HAZELTON,CA 95205 MATERIALS INVENTORY 2101 E.Earhart Ave.,Suite 100 <br /> PHONE(209)468-5420 STOCKTON,CA 95206 <br /> PHONE(209)953-6000 <br /> Part I:General Information <br /> Business,Farm or Ranch Name: Site Locations/Address(include zip code): Phone No: <br /> e t - 6✓o <br /> Mailing Address(if different from above): Description of Business/ p tion(Farm,Nursery,Etc.): a Cr :�o '/4 <br /> Emergency Contact Person: Phone No: Pesticide Permit I ID No: Fire strict: z'u Q <br /> -D 73 7 old ltkg A7 e7641 <br /> Part II: Hazardo Material Information Refer to the Agricultural Hazard Material Worksheet for the materials that should be listed below and their reportablequantities) <br /> Material Name DOT H 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 any Itime) <br /> - <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND t ; <br /> JFMAMJJASOND JAN 1 6 20?3 <br /> JFMAMJJASOND <br /> t W <br /> JFMAMJJASOND <br /> ❑ I certify that the above hazardous material information is true and correct to the best of my knowledge. �7 <br /> ✓` 7- Aditi <br /> donal Inventory Sh�eets�t tacked: <br /> Sign tore Name(please print) DateI Yes❑ No[?r <br /> (Return copleted 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.) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br /> (REV 10109/2012) <br />