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-0-1mo0 <br /> SAN JOAQUIN COUNTY WEEP 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 FE 11 201 POST OFFICE BOX 1809 <br /> PHONE(209)468-3420 STOCKTON,CA 95201-1809 <br /> SAN JOAQUIN COUNly PHONE(209)468-3300 <br /> Part I: General Information 11111EOFEMERGE <br /> Business,Farm or Ranch Name: Site Locations/Address(include zip code): Phone No: <br /> Mailing Address(if different from above): <t <br /> Description of Business/Operation(Farm,Nursery,Etc.): Nearest Crossroad: <br /> ?�d / �O>-e e e T 9 I IZ5:1�2 7'7rf/ !'ta`7''c/&X" <br /> v <br /> Emergency Contact Person: Phone No: Pesticide Permit/ID No: Fire District: <br /> role -Pr a �al 2`y4 �d x'23 �3 P* <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 H Container Container Size Max.Number Circle the Months On Site Locati2aaW on the property(e.g.in barn,NW <br /> D, 6 Typ of Containers corner of property) <br /> C <br /> y/ at anv 1 time <br /> JFMAMJJAS0ND <br /> JFMAMJJASOND y , � 7jGo I✓ <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND JAN 3 1 2011 <br /> JFMAMJJASOND WWI <br /> JFMAMJJASOND -rl . <br /> FeW'certify that the above hazardous material information is true and correct to the best of my knowledge. J <br /> Additional Inventory Sheets Attached: <br /> S' nature Name(please print) D to Yes ❑ No[] <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. 10/25/07) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br />