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-d-"/ 9 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL REAL'1'li DEPARTMENT <br />600 E MAIN ST <br />STOCKTON, CA 95202-3029 <br />PHONE (209) 468-3420 <br />Part 1: General Information <br />AGRICULTURAL HAZARDOUS <br />MATERIALS INVENTORY <br />t �Z SAN JOAQUIN COUNTY <br />OFFICE OF THE <br />1 <br />AGRICULTURAL COMMISSIONER <br />2101 E. Earhan Ave., Suite 100 <br />STOCKTON, CA 95206 <br />i AN JOAQujN coUmy PHONE (209) 953-6000 <br />:)FTiCE OF EMERGEfitCY g4wm,= <br />Business, Farm or Ranch Name: t <br />"`�._. cr F^ tC t t <br />Site Locations/Address (include zip code): <br />' if <br />Phone No: <br />ci T". Zt 4« <br />C.J t i f t 1 l <br />of Containers <br />Max. Number Circle the Months OAND <br />at an t time <br />JFMAMJJASOND <br />t �/(0 <br />Mailing Address (if different from above): <br />Description of Business/Operation (Farm, Nursery, Etc.): <br />Nearest Crossroad: <br />Emergency Contact Person: <br />Phone No: <br />Pesticide Permit / ID No: <br />Fire District: <br />Part H: Hazardous Material Information (Refer to the Agricultural Hazard Material Worksheet for the materials that should be listed below and their reportable ouantitiesl <br />Material Name <br />DOT # <br />42o'5-0c-)JFMAMJJASJFMAMJJAS <br />Container <br />Type <br />Container Size <br />of Containers <br />Max. Number Circle the Months OAND <br />at an t time <br />JFMAMJJASOND <br />ocationsts) on the property (e.g. in barn, N1W <br />orner of property) <br />JFMAMJJASOND <br />77777 <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 the best of my knowledge. <br />1 Il\ j i /1- "" % 1 Additional Inventory Sheets Attached,. <br />Signature Name (please print) Date Yes ❑ NoW <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 />