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SAN JOAQUIN COUNTY SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AGRICULTURAL HAZARDOUSOFFICE OF THE <br /> 600 E MAIN ST !p A' n AGRICULTURAL COMMISSIONER <br /> STOCKTON,CA 95202-3029 MATERIALS INVENTORY JAN 20 2101 E.Earhart Ave.,Suite 100 <br /> PHONE(209)468-3420 � STOCKTON,CA PHONE(204)95396000 <br /> 5206 <br /> 6AN JOAQUIN <br /> Part!:General Information <br /> QFPOE OF MERrE COY SAN <br /> Business,Farm or Ranch Nme. Site Locations/Address(include zip code). Phone No: <br /> L hn !' uF 1 1% . +�W 20 -712 OL 999 <br /> Mailing Address(if different from above); Description of Business/Operation(F rm,Nursery,Etc.): Nearest Crossroad: <br /> Emergency Contact Person: Phone No: Pesticide Permit/ID No: Fire District: <br /> L. m l4,u}'1V1r 2ID -112 0fg16 <br /> Part[I: Hazardous Material Information Refer to the Ag ricultural Hazard Material Worksheet for the materials that should be listed below and their reportablequantities) <br /> Material Name DOT 4 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 an I time <br /> �0 �"J MJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> F1001*certify that the above hazardous material information is true and correct to the best of my knowled e�.. r <br /> `�`1�� 4&0-0-4&�4&0-0-4f� 1— )a ��l/� 1�e ! f d I Additional Inventory Sheets Attached: <br /> Signature Name please print) Date 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. 10/15/08) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br />