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I .Z V$- I RECEIVED <br /> SAN JOAQUIN COUNTY - SAN JOAQUIN COUNTY <br /> ENVIRONMENTALHEADEPARTMENT OFFICE OF THE <br /> LTH <br /> 6AIN ST <br /> TH AGRICULTURAL HAZARDOUS DECDE 21 2 10 AGRICULTURAL COMMISSIONER <br /> STOCKTON,CA 95202-3029 MATERIALS INVENTORY POST OFFICE BOX 1809 <br /> PHONE(209)468-3420 SAN JOAQUIN UNP( STOCKTON,CA 95201-1809 <br /> CPO <br /> / R NCY SERVICES PHONE(209)468-3300 <br /> Part I:General Information C�/�L <br /> Business Farm or Ra ch Name: Site Locadons/Address(include zip code): Phone No: <br /> a S. N,4,v G> z3 6/6 <br /> Mailing Address(if different firont above): Description of Business/Operation arm,Nursery,Etc.): O t�L 6 Ne s CSa road <br /> 6d 7 //�ro�¢ l�R <br /> Emergency Contact Person: Phone No: Pesticide Permit/ID No: Fire Dis ct: <br /> Part II:Hazardo s Material Information Refer to the Agricultural Hazard Material Worksheet for the materials that should be listed below and their reportablequantities) <br /> Material Name DOT N Container Container Sin 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 an 1 time <br /> C) ?' AMJJASON � <br /> JFMAMJJASOND <br /> t 114 JFMAMJJASOND <br /> ` JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> ❑ I certify that the above hazardous material information is true and correct to JJthe best of my knowledge. <br /> 6Z41 <br /> 16 / � o dO.Zf� /..Z /e Additional Inventory Sheets ttached: <br /> Signature Name(please print) Date Yes NO <br /> (Return col pleted 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.) (rev. 10/25/07) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br />