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SAN JOAQUIN COUNTY _ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AGRICULTURAL HAZARDOUS OFFICE OF THE <br /> 600 E MAIN ST AGRICULTURAL COMMISSIONER <br /> STOCKTON,CA 95202-3029 MATERIALS INVENTORY f�F14K• c> pgc <br /> PHONE(209)468-3420 941F3L7CIfES# <br /> yHONE(20�4sa 953-60780 <br /> 2101 E Ear art ve Ste. <br /> Part I: General Information STOCKTON CA 95206 <br /> Business,Farm oRanch Name: Site Locations/Address(include zip code): Phone No: <br /> t <br /> ailing Ad ress(if different froall above): L Description of Bus' ess/Operation(Farm,Nursery,Etc.): Nearest Crossroad: <br /> `mv ZD ' r Lr�c <br /> Emergency Contact Person: Phone No: Pesticide Permit/ID No: Fire District: 1 <br /> S - 2lr <br /> Part II:Hazardous Materia nformation Refer to the Agricultural Hazard Material Worksheet for the materials that should be listed below and their reportablequantities) <br /> Material Name DOT M 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 1 time <br /> ( � 4'4 JCS r00 2 JFMAMJJASOND( Te <br /> ( JF ASOND <br /> Vt JFMAMJJASOND <br /> QJ• 2 <© DruvK �'� JFMAMJJASON0 :j7 <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND RE <br /> JFMAMJJASOND JAN 0 8 2013 <br /> JFMAMJJASOND Elm <br /> JFMAMJJASOND HEALTH DEPARTMENT <br /> JFMAMJJASOND <br /> I certify that the above hazardous material information is true and correct to the best of my knowledge. <br /> lJatiT t1 KGs' ` ! `l l Z Additional Inv nt y Sheets Attached: <br /> m-� r Name(please print) Date Ye No[--] <br /> (Return completed form(s) to the San Joaquin County Agricultural Commissioner. Do not submit fees with inventory. Yee payment will be <br /> collected based on invoicing by the Environmental Health Dept.) (rev. 10/25/07) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br />