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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 E MAIN ST <br />STOCKTON, CA 95202-3029 <br />PHONE (209) 468-3420 <br />Part L• General Information (c <br />C <br />AGRICULTURAL HAZARDOUS <br />MATERIALS INVENTORY <br />JAN — 212009 <br />SAN JOAQUIN COUNTY <br />OFFICE OF THE <br />AGRICULTURAL. COMMISSIONER <br />2101 E. Earhart Ave., Suite 100 <br />STOCKTON, CA 95206 <br />SAN �iOAn"M COUN iY PHONE (209) 953-6000 <br />OFFICE OF EMERGENCY SERVICES <br />Business, Farm or Ranch Name: Ie tA^ <br />Site I.ocations/Address (include zip code): <br />Phone No: <br />Container Size <br />d0 <br />Max. Number <br />of Containers <br />at any I time <br />( <br />Circle the Months On Site <br />—JFMAMJJASOND <br />JFMAMJJAS0N <br />JFMAMJJASOND <br />Mailing Address (if different from above): <br />Description of Business/Operation (Farm, Nursery, Etc.): <br />Nearest Crossroad: <br />2— 2 d Ll 4 !37, f::;f 4 f <br />TIT �br['1 t o <br />� ('Po t� <br />Emergency Contact Person: <br />Phone No: <br />Pesticide Permit/ ID No: <br />Fire District: <br />S.-5?45 / <br />Part If: Hazardous Material Information (Refer to the Agricultural Hazard Material Worksheet for the materials that should be listed below and their reportable quantities) <br />Material Name <br />DOT N <br />/2133S <br />Container <br />Container Size <br />d0 <br />Max. Number <br />of Containers <br />at any I time <br />( <br />Circle the Months On Site <br />—JFMAMJJASOND <br />JFMAMJJAS0N <br />JFMAMJJASOND <br />Locationstsi �theoperty (e.g. in barn, NWType <br />corner of pro <br />JFMAMJJASOND <br />JFMAMJJASOND <br />JFMAMJJASOND <br />JFMAMJJASOND <br />JFMAMJJASOND <br />JFMAMJJASOND <br />JFMAMJJASONDOR <br />v <br />JFMAMJJASOND <br />ANNx° <br />certify that the above hazardous material information Is true and correct to the best of my knowledge. •° # tt Y <br />t <br />____� LG�� �'W-� '�✓ Gc.3 1-' % %" Additional Inventory Sheets Attached: <br />Signature Name (please print) Date Yes ❑ No0 <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 />