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l'0 78 / ►vE® <br /> SAN JOAQUIN COUNTY SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AGRICULTURAL HAZARDOUSt-r 1 2009 OFFICE OF THE <br /> 600 E MAIN ST DEC AGRICULTURAL COMMISSIONER <br /> STOCKTON,CA 95202-3029 MATERIALS INVENTORY 2101 E.Emhart Ave.,Suite 100 <br /> PHONE(209)468-3420 STOCKTON,CA 95206 <br /> OFFICE OF E�ERG""' SERVICE$ PHONE(209)953-6000 <br /> Part 1:General Information <br /> Business,Farm or Ranch Name: Site Locatlons/Address(include zip code): Phone No: <br /> Mailing Address(if different from abo ): Description of usiness/Op ration(Farm,Nursery,Etc.): Nearest Crossroad: <br /> Emergency Contact Person: Pho a No: pesticide Perm! /ID No: Fire District: <br /> Part II:Hazardous Material Information Refer to the Agricultural Hazard Material Worksheet for the materials that should be listed below and their reportablequantities) <br /> Material Name DOT p 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 any Itime <br /> (C 'L JFMAMJJASOND le &- -�St�lt_ y <br /> JFMAMJJASOND �' <br /> to <br /> ell <br /> JFMAMJJASOND � <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND ,. # { �. <br /> JFMAMJJASOND _. <br /> JFMAMJJASOND DEC d 2 20U <br /> I certify that the above hazar ous material information is true and correct to the best of my knowledge. <br /> l <br /> tore Name(please print) Dale AdditionalInventory Sheetse <br /> Yes El Nolen <br /> (Return completed 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. 10/15/08) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br />